ENS Event | |
|---|---|
17:00 Jul 12, 2017 | |
| Title | Agreement State Report - Misadministration of Treatment |
| Event Description | The following information was received from the State of Colorado via email:
This is an initial report regarding a misadministration event in Colorado. University of Colorado Hospital (License Number: CO 828-01) had a misadministration of Y-90 microspheres (SIRTex SIRSpheres) on Wednesday, July 12, 2017. At approximately 11 [MDT], the post administration measurements of the waste from the SIRSpheres Administration indicated that the activity administered to segment 2/3 of the patient's liver was only 68.7 percent of the prescribed activity. The written directive called for an activity of 0.24 GBq and residual waste activity measurements indicated that 0.165 GBq was delivered. The physician indicated that stasis was not reached during the administration to this segment. There was a separate administration to segment [four] of the liver in which stasis was reached. Follow-up information will be provided after they are available. 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 Colorado Hospital Aurora, Colorado (NRC Region 4) | |
| License number: | CO 828-01 |
| Organization: | Colorado Dept Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+17.55 h0.731 days <br />0.104 weeks <br />0.024 months <br />) | |
| Opened: | Shiya Wang 10:33 Jul 13, 2017 |
| NRC Officer: | Vince Klco |
| Last Updated: | Jul 13, 2017 |
| 52851 - NRC Website | |
University Of Colorado Hospital with Agreement State | |
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