ENS 52667
ENS Event | |
|---|---|
04:00 Apr 5, 2017 | |
| Title | Agreement State Report - Less than Prescribed Dose Administered to Patient |
| Event Description | The following information was provided by the State of New York via facsimile:
On 04/05/2017, a patient with metastatic esophageal cancer received right hepatic lobar treatment [to the liver] with Y90 from SIRTEX microspheres. The intended activity was 32.9 mCi. Drawn activity was 32.7 mCi. The administered activity measured at the end of the procedure was 8.2 mCi [25 percent of intended activity]. Probable cause stated by the licensee: 'clumping' of microspheres resulting in occlusion of vial 'delivery C' needle provided by the vendor. The licensee plans to (1) request review from the manufacturer of the preparation and handling of the microspheres prior to arrival to the IR suite, (2) Since the patient is already planned for a left lobar treatment, a whole liver treatment will be planned to deliver the deficit dose to the right lobe. NY Event Report ID No. NYDOH-NY-17-06 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 | |
|---|---|
| Not Provided Not Provided, New York (NRC Region 1) | |
| License number: | NOT PROVIDED |
| Organization: | New York State Dept. Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+32.18 h1.341 days <br />0.192 weeks <br />0.0441 months <br />) | |
| Opened: | Janaki Krishnomoorthy 12:11 Apr 6, 2017 |
| NRC Officer: | Jeff Rotton |
| Last Updated: | Apr 6, 2017 |
| 52667 - NRC Website | |
Not Provided with Agreement State | |
WEEKMONTHYEARENS 550062020-11-23T04:00:00023 November 2020 04:00:00
[Table view]Agreement State Dosed Incorrect Organ ENS 543982019-11-20T18:00:00020 November 2019 18:00:00 Agreement State Agreement State Report - Iodine 125 Seed Migrated from Implant Location ENS 530172017-09-21T04:00:00021 September 2017 04:00:00 Agreement State Agreement State Report - Post Implant Loss of Iodine-125 Seed ENS 526972017-04-12T04:00:00012 April 2017 04:00:00 Agreement State Agreement State Report - Less than Intended Dose Administered to the Patient ENS 526672017-04-05T04:00:0005 April 2017 04:00:00 Agreement State Agreement State Report - Less than Prescribed Dose Administered to Patient ENS 525932017-03-04T05:00:0004 March 2017 05:00:00 Agreement State Agreement State Report - Missing Iodine 125 Calibration Sources ENS 524732016-12-29T05:00:00029 December 2016 05:00:00 Agreement State Agreement State Report - Medical Event ENS 523042016-10-17T04:00:00017 October 2016 04:00:00 Agreement State Agreement State Report - Medical Underdose ENS 519702016-05-24T04:00:00024 May 2016 04:00:00 Agreement State Agreement State Report - Medical Underdose to the Left Lobe of Liver ENS 519192015-12-02T05:00:0002 December 2015 05:00:00 Agreement State Agreement State Report - Unplanned Contamination Event ENS 513902015-09-10T04:00:00010 September 2015 04:00:00 Agreement State Agreement State Report - Medical Treatment Dose Lower than Prescribed ENS 510992015-05-27T05:00:00027 May 2015 05:00:00 Agreement State Agreement State Report - Lost Iodine-125 Medical Seeds ENS 510372015-04-30T05:00:00030 April 2015 05:00:00 Agreement State Agreement State Report - Ruptured Iodine Seed During Removal ENS 508102015-01-12T05:00:00012 January 2015 05:00:00 Agreement State Agreement State Report - Medical Misadministration During Cancer Treatment ENS 434962007-07-11T06:00:00011 July 2007 06:00:00 Agreement State Agreement State Report - Moisture Gauge Source Disconnected from Cable ENS 433012007-03-07T04:00:0007 March 2007 04:00:00 Agreement State Agreement State Report - Medical Event ENS 468952005-01-01T04:00:0001 January 2005 04:00:00 Agreement State Agreement State Report - Dose Administered >20% Different from Prescribed Dose 2020-11-23T04:00:00 | |