ENS 52880

v t e 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.

ENS 52880 +/-
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
v • d • e

v t e Emergency Notification System
Fort Sanders Regional Medical Center with Agreement State
WEEKMONTHYEAR2017-07-25T04:00:00 [Table view]
[ENS list for Fort Sanders Regional Medical Center]

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