ENS 54694
ENS Event | |
|---|---|
04:00 May 4, 2020 | |
| Title | Agreement State Report - Patient Underdose |
| Event Description | The following was received via email:
On 5/4/20, Piedmont Athens Regional Medical Center (GA 4-1) experienced a misadministration of BTG's TheraSphere Y-90 product. The plan of treatment was for [the treating physician] to deliver 120 Gy to the patient's left hepatic lobe with 1.62 GBq (43.78 milliCuries) of Y-90. The treating physician positioned the microcatheter in the left hepatic artery and verified positioning with a left hepatic arteriogram. With the microcatheter in this position, the treating physician began administering the microspheres. However, only a portion of the dose was delivered as the catheter quickly became occluded. Because of the patient's tortuous hepatic vasculature, the assessment is that a kink in the microcatheter prevented the majority of the dose from being delivered. The delivered activity was calculated by comparing pre- and post-treatment survey meter measurements of the administration equipment as outlined in TheraSphere's administration procedure. The delivered activity to the patient was 0.28 GBq (7.52 milliCuries). The delivered activity is approximately 83 percent less than the prescribed activity. Post treatment surveys of all gowns, syringes, gloves, drapes, floor coverings, and trash revealed no contamination of the surgical suite. Post treatment planar imaging revealed no extrahepatic deposition of activity. The treating physician explained our inability to deliver the full dose with the patient and a plan was made for the patient to return on 6/5/20 for a second attempt at treating the left hepatic lobe. 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 | |
|---|---|
| Georgia Radioactive Material Pgm Athens, Georgia (NRC Region 1) | |
| License number: | GA 4-1 |
| Organization: | Georgia Radioactive Material Pgm |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+33.27 h1.386 days <br />0.198 weeks <br />0.0456 months <br />) | |
| Opened: | Gregory Reese 13:16 May 5, 2020 |
| NRC Officer: | Bethany Cecere |
| Last Updated: | May 5, 2020 |
| 54694 - NRC Website | |
Georgia Radioactive Material Program with Agreement State | ||||
WEEKMONTHYEARENS 560652022-08-23T16:00:00023 August 2022 16:00:00 Agreement State Lost Radioactive Portable Gauge ENS 548822020-09-02T04:00:0002 September 2020 04:00:00 Agreement State | Agreement State Report - Medical Event - Underdose ENS 548792020-08-27T04:00:00027 August 2020 04:00:00 Agreement State | Agreement State Report - Loss of Medical Seed After Removal from Patient ENS 548172020-07-21T04:00:00021 July 2020 04:00:00 Agreement State | ENS 546942020-05-04T04:00:0004 May 2020 04:00:00 Agreement State Agreement State Report - Patient Underdose ENS 546622020-03-31T04:00:00031 March 2020 04:00:00 Agreement State Agreement State Report - Loss of Iodine-125 Seed ENS 541102019-06-11T04:00:00011 June 2019 04:00:00 Agreement State Agreement State Report - Patient Under Dosage Due to Air Being Trapped in the Delivery Line ENS 545492019-05-02T05:00:0002 May 2019 05:00:00 Agreement State Agreement State Report - Broken Density Gauge Shutter ENS 539962019-04-03T04:00:0003 April 2019 04:00:00 Agreement State Agreement State Report - Underdose Administration of Y-90 Theraspheres ENS 545502019-01-18T05:00:00018 January 2019 05:00:00 Agreement State Agreement State Report - Improper Disposal of I-125 Seed ENS 545412018-12-18T05:00:00018 December 2018 05:00:00 Agreement State Agreement State Report - Leaking Promethium-147 Source ENS 545652018-06-29T05:00:00029 June 2018 05:00:00 Agreement State Agreement State Report - Lost Iodine-125 Seed ENS 545372018-04-03T05:00:0003 April 2018 05:00:00 Agreement State Agreement State Report - Stuck Open Shutter ENS 545632017-11-06T05:00:0006 November 2017 05:00:00 Agreement State Agreement State Report - Leaking Cesium-137 Source ENS 546442017-06-09T04:00:0009 June 2017 04:00:00 Agreement State Agreement State Report - Stuck Shutter ENS 545642016-08-09T05:00:0009 August 2016 05:00:00 Agreement State Agreement State Report - Lost I-125 Source 2022-08-23T16:00:00 [Table view] | |