ENS Event | |
|---|---|
04:00 Jul 2, 2019 | |
| Title | Written Directive for Micro-Sphere Liver Treatment Was Incorrect |
| Event Description | On 7/24/19 while preparing to administer micro-sphere liver treatment the health physicist discovered that the paperwork for a previous treatment on a different patient was incorrect. The paperwork indicated that the treatment was for the left lobe of the liver. The patient's left liver was removed in a previous surgery. The prescribing physician realized that the treatment was for the right lobe of the liver and administered treatment to the right lobe. The physician failed to correct the paperwork. The treatment was on 7/2/19. The prescribed dose was 0.77 GBq and the administered dose was 0.78 GBq. There was no harm to the patient.
The licensee notified the NRC R1 Office (Tara Weidner, Penny Lanzisera). 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 | |
|---|---|
| Yale New Haven Hospital New Haven, Connecticut (NRC Region 1) | |
| License number: | 06-00819-03 |
| Organization: | Yale New Haven Hospital |
| Reporting | |
| 10 CFR 35.3045(a)(1) | |
| Time - Person (Reporting Time:+849.65 h35.402 days <br />5.057 weeks <br />1.164 months <br />) | |
| Opened: | Mike Bohan 13:39 Aug 6, 2019 |
| NRC Officer: | Kerby Scales |
| Last Updated: | Aug 6, 2019 |
| 54202 - NRC Website | |
Yale New Haven Hospital with 10 CFR 35.3045(a)(1) | |
WEEKMONTHYEARENS 542022019-07-02T04:00:0002 July 2019 04:00:00
[Table view]10 CFR 35.3045(a)(1) Written Directive for Micro-Sphere Liver Treatment Was Incorrect 2019-07-02T04:00:00 | |