ENS 54974
ENS Event | |
|---|---|
04:00 Oct 29, 2020 | |
| Title | Dose Delivered Differs by Greater than 20 Percent |
| Event Description | The following was received from Georgia Radioactive Materials Program (GA RMP) via email:
On Oct 30, 2020, [GA RMP] received an email, from the Assistant RSO [Radiation Safety Officer, Emory University], informing [GA RMP] that a second Y-90 TheraSpheres event occurred on Oct 29, 2020. A patient was administered with 16.2 mCi of Y-90 TheraSpheres using a high flow microcatheter and a larger syringe. The product representative from Boston Scientific was there to consult with the authorized users and technologist prior to treatment. Once it appeared that the micro catheter and Y-90 line and vial were in proper positioning, the Y-90 was administered. Subsequently, the line was flushed three times using approximately 50-60 ml of saline. After the procedure, all items were surveyed and calculated that only 7.3 mCi of Y-90 was administered. Since all waste was surveyed as a whole and not independently from each item, the Assistant RSO did not have the information to discern whether residual Y-90 remained in each product (micro-catheter, line, and vial). Until they can determine the causes of the misadministration, Emory has halted TheraSpheres administration at Emory at Midtown, and substituted Y-90 Sirspheres where they can. Emory University Hospital also uses TheraSpheres, but has not reported any problems. Emory investigation is ongoing. [GA RMP] will provide follow-up information as it is obtained. Georgia Incident No: 32 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 | |
|---|---|
| Emory University Atlanta, Georgia (NRC Region 1) | |
| License number: | GA 153-1 |
| Organization: | Georgia Radioactive Material Pgm |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+35.57 h1.482 days <br />0.212 weeks <br />0.0487 months <br />) | |
| Opened: | Irene Bennett 15:34 Oct 30, 2020 |
| NRC Officer: | Thomas Kendzia |
| Last Updated: | Oct 30, 2020 |
| 54974 - NRC Website | |
Emory University with Agreement State | |
WEEKMONTHYEARENS 569462024-02-01T05:00:0001 February 2024 05:00:00
[Table view]Agreement State Lost Source ENS 560072022-07-20T04:00:00020 July 2022 04:00:00 Agreement State Dose Misadministration ENS 558502022-04-11T04:00:00011 April 2022 04:00:00 Agreement State Lost/Missing Source ENS 549742020-10-29T04:00:00029 October 2020 04:00:00 Agreement State Dose Delivered Differs by Greater than 20 Percent ENS 549672020-10-23T04:00:00023 October 2020 04:00:00 Agreement State Dose Delivered Differs by Greater than 20 Percent ENS 534682018-06-21T04:00:00021 June 2018 04:00:00 Agreement State En Revision Imported Date 7/3/2018 ENS 529792017-08-24T04:00:00024 August 2017 04:00:00 Agreement State Agreement State Report - Dose Delivered 20% Greater than Prescribed and Greater than 50 Rem to the Targeted Area ENS 499172014-02-27T04:00:00027 February 2014 04:00:00 Agreement State Agreement State Report - Yttrium 90 Medical Event ENS 484412011-05-24T04:00:00024 May 2011 04:00:00 Agreement State Agreement State Report - Y-90 Therasphere Spill ENS 452462009-08-05T04:00:0005 August 2009 04:00:00 Agreement State Agreement State Report - Medical Dose Different than Prescribed ENS 443312008-05-31T04:00:00031 May 2008 04:00:00 Agreement State Agreement State - Possible Overexposure 2024-02-01T05:00:00 | |