ENS 52616

v t e ENS Event
04:00 Mar 16, 2017
Title	Agreement State Report - Patient Dosage Lower than Prescribed
Event Description	The following report was received via email: On March 16, 2017, a patient was prescribed a 12.16 milliCurie treatment dosage of Y-90 Sirspheres. As the AU [Authorized User] was pushing on the syringe he noticed a strong resistance, as did the interventional radiologist. Therefore, the administration was stopped to prevent any further safety issues. The micro catheter was pulled from the patient and the vial with the micro catheter and other radioactive waste was put in the jar for measuring. As the micro catheter was pulled, a very small defect was observed. The activity administered was 53% less than the prescribed dosage (5.64 milliCuries). The outer wrapping of the catheter was kept. The patient will be notified once recovered from the anesthesia. The licensee is investigating. The cause of the event may be a potential manufacturing defect. A reactive inspection is planned by the Department [Pennsylvania Bureau of Radiation Protection]. More information will be provided upon receipt. PA Event Report ID No: PA 170005 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 52616 +/-
Where
The American Oncology Hospital Philadelphia, Pennsylvania (NRC Region 1)
License number:	PA-0293
Organization:	Pa Bureau Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+32.87 h1.37 days <br />0.196 weeks <br />0.045 months <br />)
Opened:	Joseph Melnic 12:52 Mar 17, 2017
NRC Officer:	Bethany Cecere
Last Updated:	Mar 17, 2017
52616 - NRC Website
v • d • e

v t e Emergency Notification System
The American Oncology Hospital with Agreement State
WEEKMONTHYEAR2017-03-16T04:00:00 [Table view]
[ENS list for The American Oncology Hospital]

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