ENS Event | |
|---|---|
04:00 May 8, 2023 | |
| Title | Potential Medical Event |
| Event Description | The following information was provided by the licensee via phone and email:
In accordance with 10 CFR 35.3045, [Henry Ford Hospital is] reporting a potential medical event. On May 8, 2023, a patient was treated with Y-90 TheraSpheres. The total activity prescribed in the written directive was 11.5 mCi to the left lobe of the liver and 11.37 mCi was delivered (99.2 percent). The therapeutic dose was prescribed to be delivered to segment 4 of the left lobe of the liver. During treatment, the position of the catheter was verified and was determined by the physician to be in the correct position. However, post-treatment bremsstrahlung imaging reviewed today on 5/9/2023 indicated some activity was shunted unexpectedly to segments 2 and 3 of the left lobe of the liver. Based on preliminary calculations, this discrepancy could be categorized as a medical event.
The following information was provided by the licensee via phone: Since the exposure was due to shunting, the licensee determined that this event is not reportable in accordance with the licensing guide. This event is being retracted. Notified R3DO (Feliz-Adorno), NMSS (Rivera-Capella), and NMSS Events 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 | |
|---|---|
| Henry Ford Hospital Detroit, Michigan (NRC Region 3) | |
| License number: | 21-04109-16 |
| Organization: | Henry Ford Hospital |
| Reporting | |
| 10 CFR 35.3045(a)(2) | |
| Time - Person (Reporting Time:+35.67 h1.486 days <br />0.212 weeks <br />0.0489 months <br />) | |
| Opened: | Alan Jackson 15:40 May 9, 2023 |
| NRC Officer: | Ian Howard |
| Last Updated: | May 10, 2023 |
| 56512 - NRC Website | |
Henry Ford Hospital with 10 CFR 35.3045(a)(2) | |
WEEKMONTHYEARENS 566192023-07-11T21:00:00011 July 2023 21:00:00
[Table view]10 CFR 35.3045(a)(2) Medical Event - Dose Misadministration ENS 565122023-05-08T04:00:0008 May 2023 04:00:00 10 CFR 35.3045(a)(2) Potential Medical Event 2023-07-11T21:00:00 | |