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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 48326 | 11 September 2012 04:00:00 | Agreement State | Agreement State Report - Patient Received Underdose of Y-90 Microspheres | The following information was provided by the State of Tennessee via facsimile: On September 11, 2012, the Division of Radiological Health received a report from the University of Tennessee Medical Center regarding a misadministration that occurred September 11, 2012. A patient was prescribed a dose of 20.0 mCi of Y-90 SirSphere microspheres, and only 15.32 mCi was administered. The administered dosage was 23% less than prescribed and will result in an absorbed dose of 40.1 Gy less than the calculated 171.3 Gy. The reason why this event occurred is not known. The residual activity was detectable in the SirSpheres waste container which contained the V-vial; tubing, catheters, and protective radioactive waste cloths. The administered dosage is still considered to be within therapeutic range, but less than that prescribed by the physician. The patient and the referring physician were both notified on September 11, 2012. Inspectors from the Knoxville Field Office will follow-up on this incident. 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. |