ENS Event | |
|---|---|
04:00 Apr 25, 2017 | |
| Title | |
| Event Description | The following information was obtained from the Commonwealth of Pennsylvania via fax:
Event Description: The event involved a patient who was scheduled to be treated with 11.87 mCi of Y-90 microspheres (TheraSphere), but only received an estimated 5.07 mCi, or 43% of the prescribed dose. The licensee reported the event to the Department [Pennsylvania Department of Environmental Protection] on April 25, 2017. Initial indication is that there was a faulty connection on the catheter line that allowed a leak to occur. The patient and referring physician were notified the day of the procedure. No Jefferson personnel skin contamination occurred. However, gloves, drapes and the patient's skin were contaminated. The patient was quickly decontaminated with alcohol wipes. All remaining areas were also decontaminated. A skin calculation is currently being completed by the licensee to determine the patient's exposure, if any. No overexposure is believed to have occurred. Cause of the Event: Unknown at this time. Suspected human error. Actions: The Department will perform a reactive inspection. The licensee will update their procedure to include additional checks of the Y-90 administration kit. More information will be provided upon receipt. PA Event Report ID No.: PA170009 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 | |
|---|---|
| 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:+33.73 h1.405 days <br />0.201 weeks <br />0.0462 months <br />) | |
| Opened: | Joe Melnic 13:44 Apr 26, 2017 |
| NRC Officer: | Howie Crouch |
| Last Updated: | Apr 26, 2017 |
| 52709 - NRC Website | |
Thomas Jefferson University Hospital with Agreement State | |
WEEKMONTHYEARENS 527092017-04-25T04:00:00025 April 2017 04:00:00
[Table view]Agreement State Agreement State Report - Medical Event Due to Underdose of Yittrium-90 Theraspheres ENS 520932016-07-13T04:00:00013 July 2016 04:00:00 Agreement State Agreement State Report - Underdose Medical Event ENS 477712012-03-22T04:00:00022 March 2012 04:00:00 Agreement State Agreement State Report - Patient Received Less than Intended Dose ENS 476122012-01-20T19:09:00020 January 2012 19:09:00 Agreement State Agreement State Report - Misadministration of Dose to Patient ENS 472812011-09-16T18:14:00016 September 2011 18:14:00 Agreement State Agreement State Report - Medical Event Involving Y-90 Therasphere Underdose 2017-04-25T04:00:00 | |