ENS 55268

v t e ENS Event
17:43 May 20, 2021
Title	Patient Underdose
Event Description	The following e-mail was received from the Radiation Safety Officer (RSO) at Kootenai Health: A misadministration occurred at Kootenai Health in the Interventional Radiology Lab (ID 83814) during a Therasphere Y-90 Microsphere treatment. The prescribed dose was 66.36 mCi to segment 8 of the liver. The microspheres infusion started at 0943 PST when the micropsheres became visually clumped in the tubing of the administration set (distal to the box, prior to the microcatheter connection). Troubleshooting methods were performed, but the microspheres did not move through the tubing with multiple saline flush attempts. The infusion was aborted at 1016 PST. The room was surveyed per protocol and there was no contamination. The jar containing the tubing and microcatheter were measured per protocol. Calculations determined the patient received 12.8 mCi which was 20 percent of the prescribed dose. The RSO was notified at 1058 PST, the referring physician [was notified] at 1128 PST, and the patient [was notified] at 1150 PST. 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.

ENS 55268 +/-
Where
Kootenai Health Coeur D, Idaho (NRC Region 4)
License number:	11-27307-01
Organization:	Kootenai Health
Reporting

10 CFR 35.3045(a)(1)
Time - Person (Reporting Time:+-0.83 h-0.0346 days <br />-0.00494 weeks <br />-0.00114 months <br />)
Opened:	Rhonda Powell 16:53 May 20, 2021
NRC Officer:	Brian P. Smith
Last Updated:	May 20, 2021
55268 - NRC Website
v • d • e

v t e Emergency Notification System
Kootenai Health with 10 CFR 35.3045(a)(1)
WEEKMONTHYEAR2021-05-20T17:43:00 [Table view]
[ENS list for Kootenai Health]

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