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Start date | Reporting criterion | Title | Event description | System | LER | |
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ENS 52880 | 25 July 2017 04:00:00 | Agreement State | Agreement State Report - Misadministration Due to Problem with a Delivery Catheter | The following report was received from the Tennessee Department of Environmental Conservation Division of Radiological Health via email: (A) Yttrium-90 TheraSpheres patient procedure misadministration (occurred) due to (a) 'kinked' delivery catheter. (Approximately) 60 Gray (was) administered of (the) prescribed 120 Gray. (Two) manufacturer representatives were in attendance throughout procedure, 'proctoring' the physician. According to both proctors, the case was performed per manufacturer instructions, but unfortunately, the kinked catheter prohibited the complete dose from being administered. Tennessee Radiological Event No. TN-17-147 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. |