ENS Event | |
|---|---|
04:00 Sep 2, 2021 | |
| Title | Medical Event Involving Y-90 Microspheres |
| Event Description | The following information was received via E-mail:
On September 7, 2021 at 1535 EDT, the Virginia Radioactive Materials Program (RMP) received a report from the licensee that a medical event involving Yttrium-90 microspheres occurred on September 2, 2021 (procedure date). The Authorized User (AU) discovered the event on September 3, 2021. According to the written directive, the prescribed dose to liver segments 2 and 3 was 130 Gy and to liver segments, 4 and 8 was also 130 Gy. After the procedure, the licensee discovered that the dose intended to liver segments 2 and 3 went to liver segment 4. As a result, liver segment 4 received the unintended dose of 54 Gy and the intended dose of 130 Gy for a sum of 184 Gy, which is a difference of 41.5 percent. The licensee reported that the cause of the event was a result of incorrect location of the delivery catheter and the patient was notified on September 3, 2021. The RMP will schedule to investigate the event and this report will be updated when the final investigation report is available. Virginia Event Report ID No.: VA210005 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 | |
|---|---|
| Inova Fairfax Medical Campus Fairfax, Virginia (NRC Region 1) | |
| License number: | 610-116-1 |
| Organization: | Virginia Rad Materials Program |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+153 h6.375 days <br />0.911 weeks <br />0.21 months <br />) | |
| Opened: | Asfaw Fenta 13:00 Sep 8, 2021 |
| NRC Officer: | Donald Norwood |
| Last Updated: | Sep 8, 2021 |
| 55449 - NRC Website | |
Inova Fairfax Medical Campus with Agreement State | |
WEEKMONTHYEARENS 554492021-09-02T04:00:0002 September 2021 04:00:00
[Table view]Agreement State Medical Event Involving Y-90 Microspheres ENS 550212020-12-03T05:00:0003 December 2020 05:00:00 Agreement State Medical Event Report - Underdosage 2021-09-02T04:00:00 | |