ENS 54668

v t e ENS Event
17:15 Apr 14, 2020
Title	Agreement State Report - Medical Underdose Event of Y-90 Sirtex
Event Description	The following is a summary of an email received from the Kentucky Department of Radiation: At the University of Louisville Hospital on April 14, 2020, a patient received two doses (each dose was 0.4 GBq) of Y-90 Sirtex. The first dose was given at 1130 EDT and the second dose started at 1315 EDT. The second dose was started to be administered when a problem developed. While pushing saline into the dose V-vial, pressure built and vented out the top of the vial rather than pushing the spheres via the tubing to the patent as normal. Liquid, and presumably spheres, vented either from the side of the septum or around the needle at this time which is unknown. The administration box contained the leakage and prevented wider contamination. The second dose was not delivered to the patient so the patient received 0.4 GBq of a planned 0.8 GBq treatment. The manufacturer was contacted and the administration was stopped. Most of the intended dose remained in the plexiglass box that is used for shielding during administration. To prevent any contamination everything was kept and confined to the box. 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 54668 +/-
Where
Kentucky Dept Of Radiation Control Louisville, Kentucky (NRC Region 1)
License number:	202-029-22
Organization:	Kentucky Dept Of Radiation Control
Reporting

Agreement State
Time - Person (Reporting Time:+16.95 h0.706 days <br />0.101 weeks <br />0.0232 months <br />)
Opened:	Angela Wilbers 10:12 Apr 15, 2020
NRC Officer:	Brian P. Smith
Last Updated:	Apr 15, 2020
54668 - NRC Website
v • d • e

v t e Emergency Notification System
Kentucky Department of Radiation Control with Agreement State
WEEKMONTHYEAR2020-08-06T05:00:00 [Table view]
[ENS list for Kentucky Department of Radiation Control]

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