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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 55608 | 23 November 2021 06:00:00 | Agreement State | Underdose of Patient Medical Event | The following was received from the state of Texas (the Agency) via email: On November 24, 2021, the licensee notified the Agency that a medical event had occurred at its facility on November 23, 2021. A patient was being treated with SIRTEX SIR-spheres yttrium-90 microspheres. The order for the treatment was 8.1 millicuries. Following the procedure, it was determined the patient had only received 6.3 millicuries. The licensee reported this was not the result of stasis and is investigating to determine the cause. The licensee has contacted the manufacturer. The Authorized User stated the dose delivered should be high enough for an effective treatment. An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300. Texas Incident Number: 9896 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. | ||
| ENS 54327 | 11 October 2019 05:00:00 | Agreement State | Agreement State Report - Misadministration of Y-90 Microspheres | The following information was received from the Texas Department of State Health Services (the Agency) via E-mail: On October 11, 2019, the Agency was contacted by the licensee's radiation safety officer (RSO) who reported a medical event had occurred at their facility. The RSO stated that the event involved a patient who was to receive a treatment with yttrium-90 microspheres. The administering physician had difficulties setting up the injection apparatus and installed an additional piece of tubing in-line with the injection tubing. Because of the additional length of tubing, the patient received only five percent of the prescribed activity. The RSO stated there would be no adverse effects on the patient. The RSO stated both the patient and the prescribing physician have been notified of the error. The RSO stated that the bulk of the microspheres (activity) remained in the tubing and no contamination was found in the area where the treatment occurred. The RSO stated the physician decided they would perform the procedure again and use the activity needed to bring total activity administered to the activity initially prescribed. Additional information will be provided as it is received in accordance with SA-300. Texas Incident No.: I-9721 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. |