ENS Event | |
|---|---|
14:30 Apr 1, 2016 | |
| Title | Medical Event - Dose 75% of Prescribed Dose |
| Event Description | A patient was receiving a Y-90 Therasphere treatment to the cancer patient's liver. During the infusion, there was resistance in the tubing. The tubing was disconnected, flushed with a saline solution, and then reattached to the transfer system. The company representative was present during the procedure. After the procedure, the residual activity in the waste was determined to be approximately 25 percent of the total activity. The intended dose to the treatment area was 125 Gy with the actual dose being 94.8 Gy. The prescribing physician and the patient will be notified.
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 | |
|---|---|
| Christiana Care Health System Newark, Delaware (NRC Region 1) | |
| License number: | 07-12153-02 |
| Organization: | Christiana Care Health System |
| Reporting | |
| 10 CFR 35.3045(a)(1) | |
| Time - Person (Reporting Time:+-0.55 h-0.0229 days <br />-0.00327 weeks <br />-7.5339e-4 months <br />) | |
| Opened: | Carol Wen 13:57 Apr 1, 2016 |
| NRC Officer: | Mark Abramovitz |
| Last Updated: | Apr 1, 2016 |
| 51843 - NRC Website | |
Christiana Care Health System with 10 CFR 35.3045(a)(1) | |
WEEKMONTHYEARENS 518432016-04-01T14:30:0001 April 2016 14:30:00
[Table view]10 CFR 35.3045(a)(1) Medical Event - Dose 75% of Prescribed Dose ENS 457212010-02-23T16:00:00023 February 2010 16:00:00 10 CFR 35.3045(a)(1) Potential Medical Event from Dosage Delivered to Different Location than Prescribed 2016-04-01T14:30:00 | |