ENS 51888

v t e ENS Event
18:05 Apr 27, 2016
Title	Medical Event - Dose Given to Incorrect Segment of the Liver
Event Description	During a Y-90 TheraSphere treatment (hepatocellular carcinoma) to the right lobe of the liver segments 5, 6, 7, and 8 (estimated volume of 1290 ml), the catheter moved and the dose was actually given to medial segment 4 (estimated volume of 330 ml). The prescribed dose was 120 Gy (3.3 GBq) and the delivered dose was approximately 118.5 Gy as determined by bremmstrahlung imaging. Segment 4 was previously treated and there was some residual cancer at this location. This dose is not expected to have detrimental effects on the patient. It is anticipated that segments 5,6,7,8 will be treated at some future time. The patient has been notified and the prescribing physician 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.

ENS 51888 +/-
Where
Spectrum Health Grand Rapids, Michigan (NRC Region 3)
License number:	21-00243-06
Organization:	Spectrum Health
Reporting

10 CFR 35.3045(a)(2)
Time - Person (Reporting Time:+-0.93 h-0.0388 days <br />-0.00554 weeks <br />-0.00127 months <br />)
Opened:	Evan Boote 17:09 Apr 27, 2016
NRC Officer:	Mark Abramovitz
Last Updated:	Apr 27, 2016
51888 - NRC Website
v • d • e

v t e Emergency Notification System
Spectrum Health with 10 CFR 35.3045(a)(2)
WEEKMONTHYEAR2016-04-27T18:05:00 [Table view]
[ENS list for Spectrum Health]

Navigation menu