ENS Event | |
|---|---|
05:00 Feb 7, 2025 | |
| Title | Medical Event |
| Event Description | The following information was received by the Ohio Department of Health via email:
On February 7, 2025, the Ohio Department of Health was notified of a medical event involving Y-90 TheraSpheres. Two patients were scheduled to receive treatment on February 7, 2025, however, patient 'A' received the dose prescribed to patient 'B'. The written directive stated patient 'A' was to receive 160 Gy (47 mCi) but instead received 92 Gy (27 mCi), resulting in an underdose of 43 percent. The apparent cause was due to transposing the vial lot numbers when entering the information into the hospital's patient tracking system. The hospital caught the error before patient 'B' was treated, and patient 'B' received the dose prescribed in the written directive. Patient 'A' and his physician were notified. The patient will be evaluated to determine if additional treatment is required. An investigation of this event is pending. Ohio Item Number: OH250002 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 | |
|---|---|
| Riverside Methodist Hospital Columbus, Ohio (NRC Region 3) | |
| License number: | 02120250070 |
| Organization: | Ohio Bureau Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+77.5 h3.229 days <br />0.461 weeks <br />0.106 months <br />) | |
| Opened: | Michael Rubadue 10:30 Feb 10, 2025 |
| NRC Officer: | Kerby Scales |
| Last Updated: | Feb 10, 2025 |
| 57538 - NRC Website | |
Riverside Methodist Hospital with Agreement State | |
WEEKMONTHYEARENS 575382025-02-07T05:00:0007 February 2025 05:00:00
[Table view]Agreement State Medical Event ENS 558522022-04-18T04:00:00018 April 2022 04:00:00 Agreement State Patient Underdose ENS 463332010-04-06T04:00:0006 April 2010 04:00:00 Agreement State Ohio Agreement State Report - D90 Dose Less than Prescribed Dose ENS 413582005-01-24T05:00:00024 January 2005 05:00:00 Agreement State Agreement State Report of Administration of Radioactive Iodine to a Pregnant Patient 2025-02-07T05:00:00 | |