ENS Event | |
|---|---|
04:00 Jul 25, 2017 | |
| Title | Agreement State Report - Misadministration Due to Problem with a Delivery Catheter |
| Event Description | The following report was received from the Tennessee Department of Environmental Conservation Division of Radiological Health via email:
[A] Yttrium-90 TheraSpheres patient procedure misadministration [occurred] due to [a] 'kinked' delivery catheter. [Approximately] 60 Gray [was] administered of [the] prescribed 120 Gray. [Two] manufacturer representatives were in attendance throughout procedure, 'proctoring' the physician. According to both proctors, the case was performed per manufacturer instructions, but unfortunately, the kinked catheter prohibited the complete dose from being administered. Tennessee Radiological Event No. TN-17-147 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 | |
|---|---|
| Fort Sanders Regional Medical Center Knoxville, Tennessee (NRC Region 1) | |
| License number: | R-47003 |
| Organization: | Tennessee Div Of Rad Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+174.47 h7.27 days <br />1.039 weeks <br />0.239 months <br />) | |
| Opened: | Andrew Holcomb 10:28 Aug 1, 2017 |
| NRC Officer: | Jeff Herrera |
| Last Updated: | Aug 1, 2017 |
| 52880 - NRC Website | |
Fort Sanders Regional Medical Center with Agreement State | |
WEEKMONTHYEARENS 528802017-07-25T04:00:00025 July 2017 04:00:00
[Table view]Agreement State Agreement State Report - Misadministration Due to Problem with a Delivery Catheter 2017-07-25T04:00:00 | |