The following was received from the State of
Wisconsin via email:
On December 4, 2017, the department [State of Wisconsin Department of Health Services] received a telephone call and email from the licensee's lead nuclear medicine technologist about a Y-90 TheraSphere dose that was not delivered as prescribed to the patient. The procedure occurred at 11:00 AM on December 4, 2017. The written directive stated that the dose delivered should be 120 Gy. The estimated dose delivered to the liver was 17.7 Gy. The nuclear medicine technologist discovered contamination in the operating room where the procedure took place, which implied that some of the dose did not get into the patient during the treatment. The licensee is suspecting that there was an issue with the administration kit. The licensee has contacted the manufacturer and the manufacturer is planning a site visit. The licensee has removed the contaminated administration kit and placed it in a waste bag for decay in storage. The room where the administration occurred has also been cleaned. The department [State of Wisconsin Department of Health Services] will follow up with a site visit to investigate the incident.
Event Report ID No.: WI170019
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.
- * * UPDATE FROM DAVID REINDL TO VINCE KLCO ON 12/19/17 AT 1217 EST * * *
The following information was excerpted from an email received from the State of Wisconsin:
. . . After performing a site visit on December 14, 2017 it was determined that there was actually no contamination resulting from this event. The licensee requested that we amend the notice to reflect this change . . . . In the publicly available text there are two statements that should be changed. The text 'The nuclear medicine technologist discovered contamination in the operating room where the procedure took place, which implied that some of the dose did not get into the patient during the treatment' should be changed to 'The nuclear medicine technologist discovered no contamination in the operating room where the procedure took place'. Additionally the following text should be deleted, 'The room where the administration occurred has also been cleaned'.
Notified the R3DO (Dickson) and
NMSS Events Notification Group via email.