ENS Event | |
|---|---|
16:00 Jun 4, 2021 | |
| Title | Medical Event Underdose |
| Event Description | The following event was received from the South Carolina Department of Health [the Department] via email:
The licensee notified the Department on June 7, 2021 at 1300 [EDT] that it had determined at 1200 [EDT] a medical event had occurred because of a Y-90 Therasphere procedure that occurred on June 4, 2021. The licensee is reporting that the administered dose differed from the prescribed dose by more that 20 percent. The written directive specified that the patient was to be administered with 135.5 mCi of Y-90 Therasphere to the left lobe of the liver. During the procedure it was discovered that there was an apparent leak in the microcatheter. The dose delivered calculated to be less than 93 mCi. The remainder of the dose had leaked onto the floor. The licensee has decontaminated the room. The On-call Duty Officer is meeting with the licensee's Radiation Safety Officer on June 8, 2021 to investigate this incident. This is an initial notification and further updates will be forthcoming once the investigation is complete. 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 | |
|---|---|
| Prisma Health Greenville Memorial Hospital Greenville, South Carolina (NRC Region 1) | |
| License number: | L275 |
| Organization: | South Carolina Department Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+86.57 h3.607 days <br />0.515 weeks <br />0.119 months <br />) | |
| Opened: | Andrew Roxburgh 06:34 Jun 8, 2021 |
| NRC Officer: | Brian P. Smith |
| Last Updated: | Jun 8, 2021 |
| 55296 - NRC Website | |
Prisma Health Greenville Memorial Hospital with Agreement State | |
WEEKMONTHYEARENS 552962021-06-04T16:00:0004 June 2021 16:00:00
[Table view]Agreement State Medical Event Underdose 2021-06-04T16:00:00 | |