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. |
| 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 | |
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 | |