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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 53743 | 16 November 2018 06:00:00 | Agreement State | Agreement State Report - Misadministration of Therasphere Microspheres | The following information was received via E-mail: On November 16, 2018, the Agency (Texas Department of State Health Services) was notified by the licensee that a medical event had occurred earlier that day. The event occurred when the licensee attempted to treat a patient with 220 grays of Yttrium-90 (TheraSphere) microspheres. After the treatment the injection catheter was removed from the device and placed in a storage container. A survey of the container indicated the dose rate was half of the dose rate prior to injection. The licensee stated they believe only 107.1 Grays of the spheres had been injected into the patient. The licensee did not provide the target organ, but will provide it in the written report. The licensee stated the patient would not experience any adverse effects from the event. The licensee stated no individual performing the treatment received any significant exposure. The licensee stated the area was not contaminated. The licensee did not have a cause for the event, but will provide it once determined. Additional information will be provided as it is received in accordance with SA-300. Texas Incident Number: I - 9636 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. |