The following information was provided by the
Arkansas Department of Health, Radiation Control Radioactive Material Program (the Agency) via email:
The radiation safety officer for Central Arkansas Radiation Therapy Institute (CARTI) contacted the Agency on March 21, 2024, to advise of a yttrium-90 (Y-90) microsphere therapy administration in which the patient received 20 percent greater than the prescribed dose. The administration occurred on February 7, 2024. Treatment was only to one side of the liver. The amount was localized to the liver. The physician felt the delivered dose was clinically effective, and no further treatment is planned. No adverse patient impacts are expected.
The discovery was made during a quarterly review of their written directive on March 20, 2024.
The Agency is awaiting further information from the licensee.
- * * UPDATE ON 4/25/24 AT 1045 EDT FROM SUSAN ELLIOTT TO BILL GOTT * * *
The following information was provided by the Arkansas Department of Health, Radiation Control Radioactive Material Program (the Agency) via email:
The discovery was made during a quarterly review of their written directive on March 12, 2024 (Corrected date).
The authorized user prescribed an activity of 2.6 GBq (70 mCi) on February 7, 2024. The technologist drew up 3.17 GBq (85.8 mCi) which was 122 percent of the prescribed activity and delivered the syringe to the authorized user. The authorized user performed the administration within 30 minutes of the dose being drawn. The administered activity was estimated to be 84.5 mCi, 120 percent of the prescribed activity.
The authorized user contacted the patients referring physician and both were satisfied with the activity delivered as the goal was to ablate the entire segment of diseased liver. The absorbed doses to all other tissues were below the targets for treatment with Y90.
Personnel interviews were conducted by the department on April 2, 2024, aimed at gaining insight into the incident and engaging in discussions regarding the procedures involved.
The event is considered closed.
Notified R4DO (Warnick) and NMSS Events Notification (email)
Arkansas Event #: AR-2024-2
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.