ENS 53468
ENS Event | |
|---|---|
04:00 Jun 21, 2018 | |
| Title | En Revision Imported Date 7/3/2018 |
| Event Description | EN Revision Text: AGREEMENT STATE REPORT - DOSE MISADMINISTRATION
The following information was received from the State of Georgia via email; RMP [Georgia Radioactive Materials Program] received a call regarding an event that occurred at the main Emory Campus. A 57 year old male was treated on June 21, 2018 with 81.1 mCi of Y-90 Therasphere. The treatment site was the right lobe of the liver. Approximately an hour after the treatment the patient was scanned. The scan indicated that approximately 80% of the administered dose went to the left lobe, 10% went to the right lobe and some went to the stomach and some went to the 1st portion of the duodenum. It was determined there was a vessel spasm during the treatment that caused the theraspheres to shunt to the left lobe of the liver. 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. Georgia Incident Report # 3.
The following information was received from the State of Georgia via email: [The Georgia Radioactive Materials Program] received Emory's report regarding the Y-90 procedure and verified the backflow to the left lobe was due to shunting. Based on this information, [Georgia has] determined that this is not a medical event. All documentation will be filed in the licensee's file and electronically. Notified the R1DO (Powell) and the NMSS Events Group via email. |
| Where | |
|---|---|
| Emory University Atlanta, Georgia (NRC Region 1) | |
| License number: | GA 153-1 |
| Organization: | Georgia Radioactive Material Pgm |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+34.43 h1.435 days <br />0.205 weeks <br />0.0472 months <br />) | |
| Opened: | Irene Bennett 14:26 Jun 22, 2018 |
| NRC Officer: | Thomas Kendzia |
| Last Updated: | Jul 2, 2018 |
| 53468 - NRC Website | |
Emory University with Agreement State | |
WEEKMONTHYEARENS 569462024-02-01T05:00:0001 February 2024 05:00:00
[Table view]Agreement State Lost Source ENS 560072022-07-20T04:00:00020 July 2022 04:00:00 Agreement State Dose Misadministration ENS 558502022-04-11T04:00:00011 April 2022 04:00:00 Agreement State Lost/Missing Source ENS 549742020-10-29T04:00:00029 October 2020 04:00:00 Agreement State Dose Delivered Differs by Greater than 20 Percent ENS 549672020-10-23T04:00:00023 October 2020 04:00:00 Agreement State Dose Delivered Differs by Greater than 20 Percent ENS 534682018-06-21T04:00:00021 June 2018 04:00:00 Agreement State En Revision Imported Date 7/3/2018 ENS 529792017-08-24T04:00:00024 August 2017 04:00:00 Agreement State Agreement State Report - Dose Delivered 20% Greater than Prescribed and Greater than 50 Rem to the Targeted Area ENS 499172014-02-27T04:00:00027 February 2014 04:00:00 Agreement State Agreement State Report - Yttrium 90 Medical Event ENS 484412011-05-24T04:00:00024 May 2011 04:00:00 Agreement State Agreement State Report - Y-90 Therasphere Spill ENS 452462009-08-05T04:00:0005 August 2009 04:00:00 Agreement State Agreement State Report - Medical Dose Different than Prescribed ENS 443312008-05-31T04:00:00031 May 2008 04:00:00 Agreement State Agreement State - Possible Overexposure 2024-02-01T05:00:00 | |