ENS 54327

From kanterella

Jump to navigation Jump to search

v t e ENS Event
05:00 Oct 11, 2019
Title	Agreement State Report - Misadministration of Y-90 Microspheres
Event Description	The following information was received from the Texas Department of State Health Services (the Agency) via E-mail: On October 11, 2019, the Agency was contacted by the licensee's radiation safety officer (RSO) who reported a medical event had occurred at their facility. The RSO stated that the event involved a patient who was to receive a treatment with yttrium-90 microspheres. The administering physician had difficulties setting up the injection apparatus and installed an additional piece of tubing in-line with the injection tubing. Because of the additional length of tubing, the patient received only five percent of the prescribed activity. The RSO stated there would be no adverse effects on the patient. The RSO stated both the patient and the prescribing physician have been notified of the error. The RSO stated that the bulk of the microspheres (activity) remained in the tubing and no contamination was found in the area where the treatment occurred. The RSO stated the physician decided they would perform the procedure again and use the activity needed to bring total activity administered to the activity initially prescribed. Additional information will be provided as it is received in accordance with SA-300. Texas Incident No.: I-9721 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 54327 +/-
Where
Memorial Hermann Health System Houston, Texas (NRC Region 4)
License number:	RAM - L00650
Organization:	Texas Dept Of State Health Services
Reporting

Agreement State
Time - Person (Reporting Time:+13.48 h0.562 days <br />0.0802 weeks <br />0.0185 months <br />)
Opened:	Arthur Tucker 18:29 Oct 11, 2019
NRC Officer:	Donald Norwood
Last Updated:	Oct 11, 2019
54327 - NRC Website
v • d • e

v t e Emergency Notification System
Memorial Hermann Health System with Agreement State
WEEKMONTHYEAR2021-11-23T06:00:00 [Table view]
[ENS list for Memorial Hermann Health System]

Retrieved from "https://kanterella.com/w/index.php?title=ENS_54327&oldid=1961506"

ENS Notification