ENS Event | |
|---|---|
14:00 Aug 11, 2016 | |
| Title | Agreement State Report - Underadministration of Y-90 Microspheres |
| Event Description | The following was received from State of Maryland via email:
Greater than 20 percent underadministration of the prescribed activity was administered to the left lobe of the patient's liver. Underadministration may have been up to 60 percent less than the prescribed written activity (preliminary estimate). Prescribed written directive activity to left lobe of liver was 25 mCi. Preliminary assessment of administered activity is 14 mCi. Radioactive material ended up in the patient catheter, chucks, and on the floor. All areas were cleaned and evaluated by the licensee. The licensee states that both the patient and referring doctor have been notified of the event. The licensee has history of many successful therapies of this type. The licensee is investigating the event, but has not yet determined a root cause. The licensee is sending a detailed written report to the State. 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 | |
|---|---|
| University Of Maryland, Baltimore Baltimore, Maryland (NRC Region 1) | |
| License number: | 07-014-01 |
| Organization: | Maryland Dept Of The Environment |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+24.88 h1.037 days <br />0.148 weeks <br />0.0341 months <br />) | |
| Opened: | Ray Manley 14:53 Aug 12, 2016 |
| NRC Officer: | Dong Park |
| Last Updated: | Aug 12, 2016 |
| 52176 - NRC Website | |
University Of Maryland, Baltimore with Agreement State | |
WEEKMONTHYEARENS 521762016-08-11T14:00:00011 August 2016 14:00:00
[Table view]Agreement State Agreement State Report - Underadministration of Y-90 Microspheres 2016-08-11T14:00:00 | |