ENS 56440
ENS Event | |
|---|---|
02:30 Mar 29, 2023 | |
| Title | Dose Above Prescribed Dose |
| Event Description | The following information was provided by the Massachusetts Radiation Control Program (MA RCP) via email:
On 3/29/2023 at 1353 EDT, the Radiation Safety Officer (RSO) at Tufts Medical Center reported a medical event, misadministration, to the MA Radiation Control Program. On 3/28/2023 at 2230 EDT, the licensee discovered that a patient was administered, on the same date shortly before the discovery, a therapeutic activity of 37.9 mCi of Y-90 microspheres to the right lobe of the liver instead of the intended total of 11 mCi in a two-step successive administration per written directive. The patient and the referring physician have been notified. It was reported by the RSO that the administering physician determined that there will be no adverse effect to the patient as a result of the event. The cause of the event has initially attributed to human error by the administering technologist. The error was the improper application of a dose calibrator correction factor for the administration of Y-90 microspheres. A correction factor of 10 was not applied as per procedure. As a result, the technologist drew an activity of 60.3 mCi into the vial instead of 6.03 mCi as per the written directive for the first dose in an intended two step successive administration up to 11 mCi. The actual stasis administration was 37.9 mCi, which is the portion actually delivered to the right lobe of the liver via the delivery apparatus resulting in overloading. No further administrations to the patient occurred. At 1538 EDT on 3/29/2023, the Tufts RSO was contacted to discuss the facility's immediate corrective action. MA RCP recommended that the technologist responsible for the event not be allowed to perform any further therapeutic or diagnostic procedures at this time due to their failure to follow procedures (written directive). The Tufts RSO agreed. It was also agreed that he would contact the administering physician and forward the request for the dose conversion from mCi to rads or Grays to the target tumor. Tufts will provide any additional immediate corrective actions and the delivered dose estimate to the Radiation Control Program in a preliminary summary report on 3/30/2023. MA Event Number: TBD 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 | |
|---|---|
| Tufts Medical Center Boston, Massachusetts (NRC Region 1) | |
| License number: | 60-0160 |
| Organization: | Ma Radiation Control Program |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+34.98 h1.458 days <br />0.208 weeks <br />0.0479 months <br />) | |
| Opened: | Kenath Traegde 13:29 Mar 30, 2023 |
| NRC Officer: | Adam Koziol |
| Last Updated: | Mar 30, 2023 |
| 56440 - NRC Website | |
Tufts Medical Center with Agreement State | |
WEEKMONTHYEARENS 564402023-03-29T02:30:00029 March 2023 02:30:00
[Table view]Agreement State Dose Above Prescribed Dose ENS 555572021-11-02T17:25:0002 November 2021 17:25:00 Agreement State Y-90 Microsphere Medical Event ENS 490492013-05-17T04:00:00017 May 2013 04:00:00 Agreement State Massachusetts Agreement State Report - Medical Event Concerning Gamma Knife Therapy ENS 508322012-02-10T05:00:00010 February 2012 05:00:00 Agreement State Agreement State Report - Medical Overdose 2023-03-29T02:30:00 | |