ENS 55006
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ENS Event | |
|---|---|
04:00 Nov 23, 2020 | |
| Title | Dosed Incorrect Organ |
| Event Description | The following information was received from the state of New York via fax:
A medical licensee reported on 11/23/2020 that a Y90 microsphere procedure performed on Friday 11/20/2020 was later discovered to have had the catheter connected to the gallbladder instead of the liver as prescribed in the written directive. More information will be forthcoming but preliminary information shows that the microspheres were Sirtex SIR-Spheres. New York Incident Number: NYDOH-20-07. 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 | |
|---|---|
| Not Provided New York (NRC Region 1) | |
| License number: | Not Provided |
| Organization: | New York State Dept. Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+32.33 h1.347 days <br />0.192 weeks <br />0.0443 months <br />) | |
| Opened: | Daniel J. Samson 12:20 Nov 24, 2020 |
| NRC Officer: | Solomon Sahle |
| Last Updated: | Nov 24, 2020 |
| 55006 - NRC Website | |
Not Provided with Agreement State | |
WEEKMONTHYEARENS 550062020-11-23T04:00:00023 November 2020 04:00:00
[Table view]Agreement State Dosed Incorrect Organ ENS 543982019-11-20T18:00:00020 November 2019 18:00:00 Agreement State Agreement State Report - Iodine 125 Seed Migrated from Implant Location ENS 530172017-09-21T04:00:00021 September 2017 04:00:00 Agreement State Agreement State Report - Post Implant Loss of Iodine-125 Seed ENS 526972017-04-12T04:00:00012 April 2017 04:00:00 Agreement State Agreement State Report - Less than Intended Dose Administered to the Patient ENS 526672017-04-05T04:00:0005 April 2017 04:00:00 Agreement State Agreement State Report - Less than Prescribed Dose Administered to Patient ENS 525932017-03-04T05:00:0004 March 2017 05:00:00 Agreement State Agreement State Report - Missing Iodine 125 Calibration Sources ENS 524732016-12-29T05:00:00029 December 2016 05:00:00 Agreement State Agreement State Report - Medical Event ENS 523042016-10-17T04:00:00017 October 2016 04:00:00 Agreement State Agreement State Report - Medical Underdose ENS 519702016-05-24T04:00:00024 May 2016 04:00:00 Agreement State Agreement State Report - Medical Underdose to the Left Lobe of Liver ENS 519192015-12-02T05:00:0002 December 2015 05:00:00 Agreement State Agreement State Report - Unplanned Contamination Event ENS 513902015-09-10T04:00:00010 September 2015 04:00:00 Agreement State Agreement State Report - Medical Treatment Dose Lower than Prescribed ENS 510992015-05-27T05:00:00027 May 2015 05:00:00 Agreement State Agreement State Report - Lost Iodine-125 Medical Seeds ENS 510372015-04-30T05:00:00030 April 2015 05:00:00 Agreement State Agreement State Report - Ruptured Iodine Seed During Removal ENS 508102015-01-12T05:00:00012 January 2015 05:00:00 Agreement State Agreement State Report - Medical Misadministration During Cancer Treatment ENS 434962007-07-11T06:00:00011 July 2007 06:00:00 Agreement State Agreement State Report - Moisture Gauge Source Disconnected from Cable ENS 433012007-03-07T04:00:0007 March 2007 04:00:00 Agreement State Agreement State Report - Medical Event ENS 468952005-01-01T04:00:0001 January 2005 04:00:00 Agreement State Agreement State Report - Dose Administered >20% Different from Prescribed Dose 2020-11-23T04:00:00 | |
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