ENS Event | |
|---|---|
19:00 Aug 18, 2017 | |
| Title | Medical Event - Y-90 Theraspheres Administered to the Wrong Liver Lobe |
| Event Description | A medical event occurred on 8/18/2017 when Y-90 TheraSpheres meant for treatment of the patient's left liver lobe were administered to the patient's right liver lobe. The patient treatment plan was for radioembolization of the left lobe of the liver on 8/18/17 and radioembolization of the right liver lobe approximately one month later. The interventional radiologist (IR) and radiation oncologist authorized user (AU) signed off on planning activity for the left lobe via the left hepatic artery on 8/2/17 and 8/3/17, respectively. The AU completed the 8/18/17 written directive to deliver 124 Gy to the left lobe via the left hepatic artery (LHA). The IR placed the catheter for treatment in the right hepatic artery which supplies the right liver lobe. The AU, medical physicist and radiation technologist came to the procedure room. A time out procedure was done asking all parties to confirm 124 Gy to the left lobe via the LHA. The IR gave a verbal affirmation of this plan. The IR discovered the error when reviewing patient notes following the procedure. He immediately notified the AU who then notified the Radiation Safety Officer (RSO). The AU estimated dose to the right lobe to be 63 Gy. The RSO continues investigating the event. The patient and the referring physician were notified of the medical event.
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 | |
|---|---|
| Washington University St. Louis, Missouri (NRC Region 3) | |
| License number: | 24-00167-11 |
| Organization: | Washington University |
| Reporting | |
| 10 CFR 35.3045(a)(3) | |
| Time - Person (Reporting Time:+21.23 h0.885 days <br />0.126 weeks <br />0.0291 months <br />) | |
| Opened: | Susan Langhorst 16:14 Aug 19, 2017 |
| NRC Officer: | Donald Norwood |
| Last Updated: | Aug 19, 2017 |
| 52917 - NRC Website | |
Washington University with 10 CFR 35.3045(a)(3) | |
WEEKMONTHYEARENS 529172017-08-18T19:00:00018 August 2017 19:00:00
[Table view]10 CFR 35.3045(a)(3) Medical Event - Y-90 Theraspheres Administered to the Wrong Liver Lobe 2017-08-18T19:00:00 | |