ENS 54057

v t e ENS Event
23:17 May 8, 2019
Title	Administration of Less than Prescribed Dose
Event Description	This was a Y-90 TheraSphere administration [120 Gy to the right lobe of the liver]. The catheter was guided to the right hepatic artery and the position was verified by fluoroscopy. No issues with catheter flow while administering contrast and normal saline. The catheter was connected to the primed infusion system and the dose delivery was initiated. The IR (Interventional Radiology) physician, under the supervision of the Authorized User, was delivering the dose. The IR physician saw several small air bubbles in the delivery line and then experienced high resistance. Some of the Y-90 activity (approximately 13.2 mCi or 0.49 GBq) was delivered to the patient. Approximately 60% of the activity was in the administration set and catheter. No contamination of the IR suite or of any of the personnel occurred. All of the dose was either in the delivery system/catheter or the patient. No harm was done to the patient since the activity was delivered to the target organ and the dose did not exceed the prescribed dose. The referring physician and the patient were notified within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />. 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.

ENS 54057 +/-
Where
Queens Medical Center Honolulu, Hawaii (NRC Region 4)
License number:	53-16533-02
Organization:	Queens Medical Center
Reporting

10 CFR 35.3045(a)(2)
Time - Person (Reporting Time:+18.85 h0.785 days <br />0.112 weeks <br />0.0258 months <br />)
Opened:	Dale Schippers 18:08 May 9, 2019
NRC Officer:	Thomas Kendzia
Last Updated:	May 9, 2019
54057 - NRC Website
v • d • e

v t e Emergency Notification System
Queens Medical Center with 10 CFR 35.3045(a)(2)
WEEKMONTHYEAR2019-05-08T23:17:00 [Table view]
[ENS list for Queens Medical Center]

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