ENS Event | |
|---|---|
06:00 Aug 20, 2019 | |
| Title | Agreement State - Less than Prescribed Dose Received |
| Event Description | The following was received from the State of Kentucky via e-mail:
The University of Kentucky reported that a patient received less dose than prescribed on 8/20/2019. The patient was prescribed to receive 429.2 MBq (11.6 mCi) of Y-90 microspheres (Sirtex Medical model SIR- Spheres). A microsphere dose of 425.5 MBq (11.5 mCi) was drawn from the unit vial into the administration vial. However, the patient only received an activity of 316.72 MBq (8.56 mCi), which is 26.2 percent less than prescribed, because some microspheres remained in the administration system. Additionally, it was difficult to draw 429.2 MBq (11.6 mCi) from the 7.13 GBq (192.6 mCi) in the unit vial as it represented only a small portion of the whole. The patient and referring physician were notified. Corrective actions included ordering a dose calibrated to more closely provide the activity needed for the date and time of administration. If the activity to be administered is low, the university will ensure that the activity drawn is 10 percent greater than prescribed. More flushes of the system will also be performed in hopes of pushing more of the residual activity into the patient. Kentucky Incident Number - 190008. NMED Item Number - 190442 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 | |
|---|---|
| Kentucky Dept Of Radiation Control Lexington, Kentucky (NRC Region 1) | |
| License number: | KY-202-049-22 |
| Organization: | Kentucky Dept Of Radiation Control |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+3536.87 h147.37 days <br />21.053 weeks <br />4.845 months <br />) | |
| Opened: | Angela Wilbers 15:52 Jan 14, 2020 |
| NRC Officer: | Kerby Scales |
| Last Updated: | Jan 14, 2020 |
| 54477 - NRC Website | |
Kentucky Department of Radiation Control with Agreement State | |
WEEKMONTHYEARENS 548682020-08-30T15:15:00030 August 2020 15:15:00
[Table view]Agreement State Agreement State Report - Stolen Moisture Density Gauge ENS 548212020-08-06T05:00:0006 August 2020 05:00:00 Agreement State Agreement State Report - Stuck Shutter ENS 546762020-04-22T15:42:00022 April 2020 15:42:00 Agreement State Agreement State Report - Gauge System Switch Failure ENS 546682020-04-14T17:15:00014 April 2020 17:15:00 Agreement State Agreement State Report - Medical Underdose Event of Y-90 Sirtex ENS 545132020-02-06T12:15:0006 February 2020 12:15:00 Agreement State Agreement State Report - Fixed Process Gauge Shutter Malfunction ENS 544772019-08-20T06:00:00020 August 2019 06:00:00 Agreement State Agreement State - Less than Prescribed Dose Received 2020-08-06T05:00:00 | |