ENS Event | |
|---|---|
15:05 Oct 12, 2017 | |
| Title | Agreement State Report - Dose Delivered Less than Prescribed |
| Event Description | The following information was received from the State of Ohio via email:
On 10/12/17 during an infusion of Y-90 SIRSpheres that began at 11:05 a.m. [EDT], the treatment device malfunctioned and ceased delivery of the radioisotope, resulting in an under-dosing of the patient's liver. No contamination of the facilities or personnel was detected. All activity that was not delivered into the patient was placed back into the acrylic box and secured in the nuclear medicine hot lab for decay. A SIRSpheres representative was present during the treatment, but the cause of the malfunction is not known at this time. Once sufficient decay of the radioisotope has occurred, the delivery device will be shipped to SIRSpheres for technical analysis and root cause determination. The patient was informed on the day of the event. Ohio Item Number: OH170006 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 | |
|---|---|
| Adena Regional Medical Center Chillicothe, Ohio (NRC Region 3) | |
| License number: | 02120720000 |
| Organization: | Ohio Bureau Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+22.67 h0.945 days <br />0.135 weeks <br />0.0311 months <br />) | |
| Opened: | Michael J. Rubadue 13:45 Oct 13, 2017 |
| NRC Officer: | Richard Smith |
| Last Updated: | Oct 13, 2017 |
| 53011 - NRC Website | |
Adena Regional Medical Center with Agreement State | |
WEEKMONTHYEARENS 530112017-10-12T15:05:00012 October 2017 15:05:00
[Table view]Agreement State Agreement State Report - Dose Delivered Less than Prescribed 2017-10-12T15:05:00 | |