ENS 53544
ENS Event | |
|---|---|
07:00 Aug 9, 2018 | |
| Title | Agreement State Report - Misadministration of Y-90 Microspheres |
| Event Description | The following is a summary from a report received via email from the State of Oregon:
On 08/09/18, the Oregon Health & Science University (OHSU) Radiation Safety Officer (RSO) reported a misadministered of Y-90 treatment. The activity was 294 Gy, more than twice what was in the written directive (WD), 136 Gy. The prescribed range was 109-163 Gy. The normal pre-procedure process, while still in Nuclear Medicine, includes a dose calibrator reading, which was done, and a decay calculation done based on the manufacturer's calibration data sheet. The two were within 10%. The decayed activity result (or calibrator reading) is supposed to be compared with the WD required activity before taking the dose up to Interventional Radiology (IR) for the preadministration measurements. For this case, the RSO was responsible for the calculation and verification, and should have noticed the incorrect dose before taking it to IR, but the comparison with the WD dose was not done. Another Y-90 dose had been delivered to Nuclear Medicine that morning to decay prior to a case the next week. This was the dose the Nuclear Medicine tech opened and measured, without checking the printed code on the shipping box, which includes the patient's initials. Additionally, another check is done by the nurse manager for these cases, who goes down the day before to verify what was received. The packing slip showed a 5 GBq dose, which was correct and it was the right shipping box. The interventional radiologist was informed as soon as the post-delivery calculations were confirmed. He spoke with the patient, and sent the patient to Nuclear Medicine to be imaged. The scan showed very good containment within the liver. The physician felt the patient actually should tolerate the dose, as he had considered administering a high ablation type of dose (>200 Gy), and because of where the dose was delivered. Corrective actions included a procedure modification; specifically, a dose verification step will be added when the dose is up in IR during the preliminary set-up with the nurse manager. Other steps will be put in place after further discussion. The event is being entered into the hospital notification system, and likely will receive further review at that level. The RSO will submit the full report within the required 20 days. Oregon Item Number: OR180002 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 | |
|---|---|
| Oregon Health & Science University Portland, Oregon (NRC Region 4) | |
| License number: | 90013 |
| Organization: | Or Dept Of Health Rad Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+34.48 h1.437 days <br />0.205 weeks <br />0.0472 months <br />) | |
| Opened: | Hillary Haskins 17:29 Aug 10, 2018 |
| NRC Officer: | Ossy Font |
| Last Updated: | Aug 10, 2018 |
| 53544 - NRC Website | |
Oregon Health & Science University with Agreement State | |
WEEKMONTHYEARENS 535442018-08-09T07:00:0009 August 2018 07:00:00
[Table view]Agreement State Agreement State Report - Misadministration of Y-90 Microspheres ENS 482072012-08-13T07:00:00013 August 2012 07:00:00 Agreement State Agreement State - Medical Event Involving Delivery of Underdosage ENS 427992006-02-24T07:00:00024 February 2006 07:00:00 Agreement State Oregon Agreement State Report - Vial Containing Iodine-125 Thrown in Trash Dumpster 2018-08-09T07:00:00 | |