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The following information was obtained fro … The following information was obtained from the Commonwealth of Pennsylvania via email and facsimile:</br>Notifications: On February 13, 2013 the licensee informed the Department's (Pennsylvania Department of Environmental Protection) South-central Regional Office of the medical event. The event is reportable within 24 hours per 10 CFR 35.3045(a)(1)(i). The referring physician was notified of this event but the patient passed away in November of 2012 as a result of metastatic pancreatic cancer.</br>Event Description: During a routine audit of the Y-90 written directive program, an error was noted in a SIR-Sphere procedure that was performed on August 28, 2012. The patient was prescribed 17.6 mCi of Y-90 SIR-Spheres. The patient actually received only 12.8 mCi. This corresponds to a dose that is 27.3% lower than the prescribed dose.</br>Cause of the Event: The physician recorded the wrong administered dose on the written directive form. Also a small liquid volume remained in the vial after the 'air-injection' final step.</br>Actions: The licensee initiated and completed an audit of all SIR-Sphere procedures and no other issues were identified in any other patients since inception of the program. The South-central Regional Office has been in discussion with the licensee regarding corrective actions that will be implemented.</br>Pennsylvania Event Report ID No.: PA130006</br>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.necessarily result in harm to the patient. +
05:00:00, 28 August 2012 +
48,752 +
14:28:00, 14 February 2013 +
05:00:00, 28 August 2012 +
The following information was obtained fro … The following information was obtained from the Commonwealth of Pennsylvania via email and facsimile:</br>Notifications: On February 13, 2013 the licensee informed the Department's (Pennsylvania Department of Environmental Protection) South-central Regional Office of the medical event. The event is reportable within 24 hours per 10 CFR 35.3045(a)(1)(i). The referring physician was notified of this event but the patient passed away in November of 2012 as a result of metastatic pancreatic cancer.</br>Event Description: During a routine audit of the Y-90 written directive program, an error was noted in a SIR-Sphere procedure that was performed on August 28, 2012. The patient was prescribed 17.6 mCi of Y-90 SIR-Spheres. The patient actually received only 12.8 mCi. This corresponds to a dose that is 27.3% lower than the prescribed dose.</br>Cause of the Event: The physician recorded the wrong administered dose on the written directive form. Also a small liquid volume remained in the vial after the 'air-injection' final step.</br>Actions: The licensee initiated and completed an audit of all SIR-Sphere procedures and no other issues were identified in any other patients since inception of the program. The South-central Regional Office has been in discussion with the licensee regarding corrective actions that will be implemented.</br>Pennsylvania Event Report ID No.: PA130006</br>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.necessarily result in harm to the patient. +
Has query"Has query" is a predefined property that represents meta information (in form of a <a rel="nofollow" class="external text" href="https://www.semantic-mediawiki.org/wiki/Subobject">subobject</a>) about individual queries and is provided by <a rel="nofollow" class="external text" href="https://www.semantic-mediawiki.org/wiki/Help:Special_properties">Semantic MediaWiki</a>.
00:00:00, 14 February 2013 +
PA-0127 +
Modification date"Modification date" is a predefined property that corresponds to the date of the last modification of a subject and is provided by <a rel="nofollow" class="external text" href="https://www.semantic-mediawiki.org/wiki/Help:Special_properties">Semantic MediaWiki</a>.
23:13:41, 24 November 2018 +
14:28:00, 14 February 2013 +
170.353 d (4,088.47 hours, 24.336 weeks, 5.6 months) +
05:00:00, 28 August 2012 +
URL"URL" is a <a href="/Special:Types/URL" title="Special:Types/URL">type</a> and predefined property provided by <a rel="nofollow" class="external text" href="https://www.semantic-mediawiki.org/wiki/Help:Special_properties">Semantic MediaWiki</a> to represent URI/URL values.