ENS 57320
ENS Event | |
|---|---|
06:00 Jul 18, 2024 | |
| Title | Y-90 Dose Misadministration |
| Event Description | The following is a summary of information that was provided by the New Mexico Radiation Control Program via phone and email:
At approximately 1830 MDT on September 10, 2024, the licensee's radiation safety officer discovered that on July 18, 2024, a dose of 0.2 Gbq of yttrium-90 was prescribed for delivery to a patient, but the patient received a reported dose of 0.25 Gbq. The cause for the discrepancy between the prescribed and delivered dose is unknown. The licensee has been instructed to provide a complete written report. 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.
The following information was provided by the New Mexico Radiation Control Program via email: On July 18, 2024, two microsphere radioembolization (yttrium-90) administrations were performed on the same patient. For the first dosage, 5.4 mCi was prescribed, 7.6 mCi was drawn, and 90 percent of the drawn dosage was delivered (6.84 mCi). For the second dosage, the prescribed dosage was 5.4 mCi, 7.2 mCi was drawn, and 60 percent of the drawn dosage was delivered (4.32 mCi). The first treatment is reportable because the total dosage delivered differs from the prescribed dosage by more than 20 percent and was not discovered to be due to stasis or an emergent condition. The second dosage is not reportable because the error was due to stasis as certified by the authorized user (AU). The misadministration was discovered on September 10, 2024, by the radiation safety officer (RSO) during the quarterly review of records. Upon discovery, a thorough review of the associated records was completed along with an investigation involving the lead certified nuclear medicine technologist (CNMT), the SirTex representative who was assisting with the procedure, the AU, and radiology management. It was determined that this misadministration occurred because the prescribed dosage was so small that the CNMT had a difficult time drawing it up into the syringe. When the CNMT would push one drop out of the syringe, the dosage would be too low. When adding a drop back to the syringe, the dosage would be too high. Since dosages under 10 mCi typically have a 15 percent residual, the CNMT and SirTex representative decided it was acceptable to supply a dosage that was 140 percent of the prescribed dosage, even though the facility policy is that the final activity in the syringe must be within 10 percent of the prescribed dosage. In addition, the AU was not informed that the drawn activity was outside of the allowed 10 percent range. Once it was determined that the first treatment met the definition of a medical event, the event was immediately reported. No adverse effects are anticipated. Follow up medical appointments with the patient have not indicated any immediate effects. This patient will continue to be monitored in line with standard of care. Due to the minimal risk expected due to this excess dosage, the AU along with the patient's medical oncologist decided notifying the patient would not be advisable. Notifying the patient would cause more stress than benefit. Notified R4DO (Young), NMSS Events Notification (email). |
| Where | |
|---|---|
| Lovelace Medical Center Albuquerque, New Mexico (NRC Region 4) | |
| License number: | 210-132 |
| Organization: | New Mexico Rad Control Program |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+1349.47 h56.228 days <br />8.033 weeks <br />1.849 months <br />) | |
| Opened: | Victor Diaz 11:28 Sep 12, 2024 |
| NRC Officer: | Ernest West |
| Last Updated: | Sep 23, 2024 |
| 57320 - NRC Website | |
Lovelace Medical Center with Agreement State | |
WEEKMONTHYEARENS 573202024-07-18T06:00:00018 July 2024 06:00:00
[Table view]Agreement State Y-90 Dose Misadministration ENS 459782010-05-04T06:00:0004 May 2010 06:00:00 Agreement State Agreement State Report - Medical Misadministration 2024-07-18T06:00:00 | |