ENS 51640
ENS Event | |
|---|---|
15:27 Jan 6, 2016 | |
| Title | Potentially Reportable Underdose to Patient |
| Event Description | A patient at the Henry Ford Hospital Interventional Radiology Department received a Y-90 Theraspheres treatment of 120 Gray to a portion of the left lobe of the liver via a written directive from the referring physician. The Interventional Radiologist administered the prescribed dose to the entire left lobe of the liver, and the hospital believes that will result in an underdose to the patient. The exact amount of the underdose has not determined at the time of this report. The referring physician has been notified and the licensee will inform the NRC when the patient has been notified. It is believed that this event will not result in any harm to the patient. The licensee is in the process of determining corrective action to prevent reoccurrence.
The following update information was provided by the licensee via email: Providing additional materials related to a potential medical event that was reported on January 7, 2016 by Henry Ford Hospital (License 21-04109-16; Docket: 030-02043). Hospital reported an apparent deviation from the written directive of a Y-90 TheraSpheres treatment done on January 6, 2016. The written directive was prepared in tandem by a Radiation Oncologist and a Nuclear Medicine Authorized User physicians for the major portion of the left lobe of the liver, omitting segments 4A and 4B. The entire left lobe of the liver, including segments 4A and 4B, was treated by the Interventional Radiologist. The written directive called for the administration of 2.3 GBq (62.2 mCi) of Y-90. The activity delivered was 2.37 GBq (64 mCi) which properly conformed with the activity specified in the written directive. However, the dose delivered to the liver deviates from the intended dose in two important ways. First, the written directive did not include treating segments 4A and 4B of the left lobe of the liver. Secondly, the dose delivered of 94 Gy (9,400 rad) to the left lobe of the liver was lower (21.5%) than the intended dose of 120 Gy (12,000 rad). The Interventional Radiologist, who is the referring physician for this patient, originally intended to treat the entire left lobe of the liver, including segments 4A and 4B. This Interventional Radiologist, while very experienced in TheraSpheres treatments was new to the institution and proper communication of the intended treatment site did not occur. It is important to note that all of the physicians involved indicated that no harm resulted to the patient as a result of this deviation. According to the TheraSpheres package insert, the recommended therapeutic dose to the liver is 80 Gy to 150 Gy (8,000 rad to 15,000 rad). Thus the treatment dose of 94 Gy (9,400 rad) is well within the therapeutic range. The referring physician was notified about this case and he notified the patient about the treatment deviation. Notified R3DO (Stoedter) and NMSS Events Notification group via email. A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient. |
| Where | |
|---|---|
| Henry Ford Hospital Detroit, Michigan (NRC Region 3) | |
| License number: | 21-04109-16 |
| Organization: | Henry Ford Hospital |
| Reporting | |
| 10 CFR 35.3045(a)(1) | |
| Time - Person (Reporting Time:+23.68 h0.987 days <br />0.141 weeks <br />0.0324 months <br />) | |
| Opened: | Alan Jackson 15:08 Jan 7, 2016 |
| NRC Officer: | Jeff Rotton |
| Last Updated: | Jan 8, 2016 |
| 51640 - NRC Website | |
Henry Ford Hospital with 10 CFR 35.3045(a)(1) | |
WEEKMONTHYEARENS 525242017-01-31T15:51:00031 January 2017 15:51:00
[Table view]10 CFR 35.3045(a)(1), 10 CFR 35.3045(a)(3) Potential Medical Event ENS 516402016-01-06T15:27:0006 January 2016 15:27:00 10 CFR 35.3045(a)(1) Potentially Reportable Underdose to Patient 2017-01-31T15:51:00 | |