ENS 52093

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v t e ENS Event
04:00 Jul 13, 2016
Title	Agreement State Report - Underdose Medical Event
Event Description	The following was received via email: Event Description: A patient was undergoing a Y-90 Therasphere procedure in two separate treatments (to different liver segments). The delivery kits for both administrations passed the standard pre-administration testing. The physician and team noted no other equipment related issues until the administering Interventional Radiologist Physician noted unusual resistance during the first actual administration. After unsuccessful attempts to 'clear the line,' the efforts to complete the administration were terminated. The team then attempted to treat a second site, with essentially the same sequence of events occurring. Both delivery sets came from the same manufacturing lot, and both dosages of Theraspheres came from the same drug lot. The licensee estimates approximately 25 percent of the written directive dose was delivered. Cause of the Event: Unknown at this time. It is worth noting, another Theraspheres administration on another patient was performed the following day without incident. The delivery system kits were again from the same lot as those used on the previous day, but the Therasphere dosage was from a different lot. Actions: Licensee notified Nordion of the occurrence. The Department [PA Department of Environmental Protection] will perform a reactive inspection next week. Event Report ID: PA160019 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 52093 +/-
Where
Thomas Jefferson University Hospital Philadelphia, Pennsylvania (NRC Region 1)
License number:	PA-0130
Organization:	Pa Bureau Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+58.6 h2.442 days <br />0.349 weeks <br />0.0803 months <br />)
Opened:	Joseph Melnic 14:36 Jul 15, 2016
NRC Officer:	Dong Park
Last Updated:	Jul 15, 2016
52093 - NRC Website
v • d • e

v t e Emergency Notification System
Thomas Jefferson University Hospital with Agreement State
WEEKMONTHYEAR2017-04-25T04:00:00 [Table view]
[ENS list for Thomas Jefferson University Hospital]

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