ENS 56407

v t e ENS Event
05:00 Feb 27, 2023
Title	Medical Event
Event Description	The following information was provided by the Tennessee Division of Radiological Health via email: The misadministration occurred on 2/27/23 at Methodist Germantown Hospital in the interventional radiology (IR) suite. The procedure was a Y-90 treatment for 2 separate segments. Each segment had a different dose. All documentation and a checklist were appropriately filled out and the doses were documented. The physician was to the point in the procedure to ask for the first dose. The physician asked for the 'First Dose.' The dose was brought to the physician. The dose was verbally read out and [the physician] connected the dose and administered it. The result was a treatment of the small segment, but the large dose was given. Both segments were treated, but the doses were reversed. The doses of Y-90 were as follows: 1st Prescribed Dose 79.95 Gy, Dose Given 474.7 Gy 2nd Prescribed Dose 474.7 Gy, Dose Given 79.95 Gy Corrective actions will be sent with the follow-up NMED report. State Event Report ID NO.: TN-23-013 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.

ENS 56407 +/-
Where
Methodist University Hospital Memphis, Tennessee (NRC Region 1)
License number:	R-79009-K24
Organization:	Tennessee Div Of Rad Health
Reporting

Agreement State
Time - Person (Reporting Time:+275.72 h11.488 days <br />1.641 weeks <br />0.378 months <br />)
Opened:	Andrew Holcomb 16:43 Mar 10, 2023
NRC Officer:	Caty Nolan
Last Updated:	Mar 10, 2023
56407 - NRC Website
v • d • e

v t e Emergency Notification System
Methodist University Hospital with Agreement State
WEEKMONTHYEAR2023-02-27T05:00:00 [Table view]
[ENS list for Methodist University Hospital]

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