ENS Event | |
|---|---|
16:00 Aug 24, 2021 | |
| Title | UNDER-DOSING Event with Y-90 Theraspheres |
| Event Description | The following information was received via E-mail:
On 8/24/21, a Y-90 TheraSphere treatment was to deliver a planned 13.65 GBq to the patient's anterior right hepatic lobe. The written instructions were followed in the usual fashion and the dose was administered to the patient. The catheter and administration set tubing were placed into the waste container. The patient, personnel, and room were surveyed. No spill was detected. Upon post-calculation measurements, it was found that the patient only received approximately 77 percent of the expected dose of 200 Gray. While the received 154 Gray was medically appropriate given the patient's condition, tumor type and tumor location, this treatment still fell below that intended on the written directive. Further investigation found that this patient was rescheduled multiple times and the dose had decayed further than it was planned to, the patient really should have been treated the day before on a Monday instead of the Tuesday to get the full dose as planned or a new Treatment Window Illustrator to secure a more appropriate Y-90 dose should have been completed. Patient and referring provider were notified. There were no contaminations verified by survey meter measurements. The licensee is currently implementing an Excel spreadsheet program to review accuracy prior to patient scheduling and dose ordered. Reporting Criteria under 10 CFR 35.3045. Kentucky Event Report ID No.: KY210002 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 | |
|---|---|
| St. Elizabeth Healthcare, Edgewood Edgewood, Kentucky (NRC Region 1) | |
| License number: | 202-152-27 |
| Organization: | Kentucky Dept Of Radiation Control |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+335.15 h13.965 days <br />1.995 weeks <br />0.459 months <br />) | |
| Opened: | Anjan Bhattacharyya 15:09 Sep 7, 2021 |
| NRC Officer: | Donald Norwood |
| Last Updated: | Sep 7, 2021 |
| 55447 - NRC Website | |
St. Elizabeth Healthcare, Edgewood with Agreement State | |
WEEKMONTHYEARENS 554472021-08-24T16:00:00024 August 2021 16:00:00
[Table view]Agreement State UNDER-DOSING Event with Y-90 Theraspheres 2021-08-24T16:00:00 | |