ENS Event | |
|---|---|
06:00 Jun 24, 2022 | |
| Title | Dose Delivered to Wrong Location |
| Event Description | The following information was received from the state of Colorado via facsimile:
On June 24, 2022, a patient was prescribed 1.45 GBq (39.2 mCi) of Y-90 microspheres (TheraSphere) to the right lobe of the liver, lobe estimated size of 474 grams, for a target dose of 148 Gy. However, imaging after the administration indicates that the dose was incorrectly delivered to the left lobe of the liver, lobe estimated size of 283 grams, for an estimated delivered dose of 240 Gy. The preliminary cause is based on the patient's anatomy with the left hepatic branch close to the intended treatment site. The physician's office is reaching out to the patient to notify them but has not been able to at the time of this initial notification. 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 | |
|---|---|
| Hca-Healthone, Llc Dba The Medical Center Of Aurora Aurora, Colorado (NRC Region 4) | |
| License number: | CO 305-03 |
| Organization: | Colorado Dept Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+83.12 h3.463 days <br />0.495 weeks <br />0.114 months <br />) | |
| Opened: | Phillip Peterson 17:07 Jun 27, 2022 |
| NRC Officer: | Donald Norwood |
| Last Updated: | Jun 27, 2022 |
| 55966 - NRC Website | |
Hca-Healthone, Llc Dba The Medical Center Of Aurora with Agreement State | |
WEEKMONTHYEARENS 559662022-06-24T06:00:00024 June 2022 06:00:00
[Table view]Agreement State Dose Delivered to Wrong Location 2022-06-24T06:00:00 | |