The following information was provided by the licensee via telephone:
A patient had a written directive to receive 90 Gy of Y-90 TheraSpheres to the liver. When the order was entered into the system, the wrong activity was entered. The higher activity of 360 Gy Y-90 TheraSpheres was then administered to the patient. The calculated dose to the liver may exceed 50 rem.
The patient and referring physician were informed. No health effect or permanent functional damage is expected.
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.
- * * UPDATE ON 7/9/24 AT 1644 EDT FROM JAMIE EISENBERG TO KAREN COTTON * * *
The following summary was provided by the licensee via telephone:
After further assessment of the event, it was discovered that the patient also received an unintended dose of 360 Gy Y-90 TheraSpheres to the lungs. No health effect or permanent functional damage is expected.
Notified R3DO (Nguyen), NMSS Events Notification (email), NMSS Regional Coordinator (Sun)
- * * UPDATE ON 7/10/24 AT 1250 EDT FROM JAMIE EISENBERG TO ERIC SIMPSON * * *
The following information was provided by the licensee via telephone and email as a clarification to the July 9, 2024, update:
The patient's Y-90 TheraSphere treatment resulted in an unintended dose to an organ/tissue other than the treatment site. The estimated intended dose was 0.9 Gy to the lungs. The estimated dose given the lungs was 3.29 Gy. The estimated overage was 2.39 Gy, which is 165 percent over the intended lung dose.
This administration occurred on May 6, 2024, and was the second administration of the patient's regime. The previous treatment was on April 16, 2024, and was completed as intended. The patient's cumulative lung dose from both treatments was 4.2 Gy. The planned lung dose for the regime was 1.8 Gy, again showing the approximately 2.4 Gy overage from the May 6, 2024, administration.
Notified R3DO (Nguyen),
NMSS Events Notification (email), and
NMSS Regional Coordinator (Sun)