ENS Event | |
|---|---|
05:00 May 10, 2021 | |
| Title | Dose to Improper Treatment Site |
| Event Description | The following report was received from the state of Ohio via email:
A patient was to receive a prescribed dose of 68.92 milliCuries Y-90 TheraSpheres to the left lobe of the liver on 5/10/2021. It was discovered during post treatment imaging on 5/11/2021 that the dose was delivered to the right lobe. The licensee stated the catheter position was verified prior to treatment and the cause of the event is under investigation. The referring physician and patient have been notified. Ohio Event Number: OH210003 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 | |
|---|---|
| Ohio State University Columbus, Ohio (NRC Region 3) | |
| License number: | 02110250037 |
| Organization: | Ohio Bureau Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+34.77 h1.449 days <br />0.207 weeks <br />0.0476 months <br />) | |
| Opened: | Michael Rubadue 15:46 May 11, 2021 |
| NRC Officer: | Kerby Scales |
| Last Updated: | May 11, 2021 |
| 55248 - NRC Website
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Ohio State University with Agreement State | |
WEEKMONTHYEARENS 566842023-07-28T04:00:00028 July 2023 04:00:00
[Table view]Agreement State Treatment to Wrong Side of Organ ENS 564002023-03-07T05:00:0007 March 2023 05:00:00 Agreement State Misapplication of Medical Dose Resulting in Underdosing ENS 552482021-05-10T05:00:00010 May 2021 05:00:00 Agreement State Dose to Improper Treatment Site ENS 542092019-08-06T04:00:0006 August 2019 04:00:00 Agreement State Agreement State Report - Leaking Eckert & Ziegler Cs-137 Vial Source ENS 458642010-04-20T04:00:00020 April 2010 04:00:00 Agreement State Agreement State Report - Possible Overexposure to a Member of the Public 2023-07-28T04:00:00 | |