The following report was received from the
Georgia radioactive materials program environmental protection division via email:
GA 292-1 reported on Friday 4/11/19 that a misadministration of Y-90 Theraspheres occurred on 4/3/19. It was discovered that the male patient only received 65 percent of the prescribed dose. The total dose consisted of 2 vials; the first vial was administered without any issues, but the second vial was observed as still being relatively full after being returned to nuclear medicine department for disposal. A radiation survey was completed on the vials after they were returned to the nuclear medicine department and it was noted by the department personnel that vial 2 had a higher activity then what was expected. It was later determined that vial 2 contained more dose [than expected] after performing the procedure as prescribed. The remainder of the prescribed dose was delivered to the patient on 4/5/19. Preliminary results indicate there may have been an issue with the delivery equipment (perhaps with the tubing). The radioactive materials were fully accounted for and results were confirmed by performing contamination survey, following the procedure. The RSO will submit a detailed report to the radioactive materials program within 5 days of this notification.
[On 4/18/2019] the licensee provided a written report pertaining to the event. Based on the report, no root cause has been determined at this time. The licensee suggests that the equipment can possibly be examined or sent back to the manufacturer after the radioactivity in the waste container has decreased to background levels, to determine whether any equipment defects can be found.
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.