ENS 54477

v t e 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.

ENS 54477 +/-
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
v • d • e

v t e Emergency Notification System
Kentucky Dept Of Radiation Control with Agreement State
WEEKMONTHYEAR2020-08-06T05:00:00 [Table view]
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