ENS Event | |
|---|---|
17:40 Feb 18, 2021 | |
| Title | Non-Agreement State Report - Radiopharmeceutical Under Dose |
| Event Description | The following was received via phone from the licensee:
At 1040 MST, on 2/18/21, a patient received less than the prescribed dose of 130 gray to the liver due to the catheter and device connection coming apart. The isotope was Y-90 glass microspheres. The calculated dose to the patient was 62.2 gray (47.9 percent of the prescribed dose). All non-delivered material was collected in the catheter and on absorbent material for decay and return to the manufacturer. The patient was notified of the under dose. 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 | |
|---|---|
| Kootenai Health Coeur D`Alene, Idaho (NRC Region 4) | |
| License number: | 11-27307-01 |
| Organization: | Kootenai Health |
| Reporting | |
| 10 CFR 35.3045(a)(1) | |
| Time - Person (Reporting Time:+-0.63 h-0.0263 days <br />-0.00375 weeks <br />-8.62974e-4 months <br />) | |
| Opened: | Rhonda Powell 17:02 Feb 18, 2021 |
| NRC Officer: | Bethany Cecere |
| Last Updated: | Feb 18, 2021 |
| 55107 - NRC Website | |
Kootenai Health with 10 CFR 35.3045(a)(1) | |
WEEKMONTHYEARENS 552682021-05-20T17:43:00020 May 2021 17:43:00
[Table view]10 CFR 35.3045(a)(1) Patient Underdose ENS 551072021-02-18T17:40:00018 February 2021 17:40:00 10 CFR 35.3045(a)(1) Non-Agreement State Report - Radiopharmeceutical Under Dose 2021-05-20T17:43:00 | |