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EN Revision Text: MEDICAL EVENT - Y-90 THE … EN Revision Text: MEDICAL EVENT - Y-90 THERASPHERES ADMINISTERED TO THE WRONG LIVER SEGMENT</br>A medical event occurred on 1/3/2019 at Washington University in St. Louis. The patient treatment plan called for 1.06 GBq of Y-90 TheraSpheres to be administered to Segments 6 and 7 of the patient's liver. However, 1.02 GBq of Y-90 TheraSpheres were administered to Segments 5 and 8 of the patient's liver instead.</br>The patient and the referring physician were notified of the event. Washington University in St. Louis has initiated an investigation of the event.</br>* * * RETRACTION ON 1/14/19 AT 1256 EST FROM MAXWELL AMURAO TO THOMAS KENDZIA * * *</br>The following was received via email from the licensee:</br>As a follow up to the phone call placed today (1/14/19) at 12:56 pm EST, (the licensee radiation safety officer) is writing to retract the report of a event number 53814. The initial report of a suspected medical event with the administration of Y-90 microspheres to a patient was made on 1/4/19 at 12:15 pm EST. After taking the limitations of the imaging software into account, the reviewing team of clinicians have evaluated that the Y-90 microspheres were administered to the correct patient, with the correct dosage and correct route of administration, and in agreement with the Written Directive.</br>Notified R3DO (PELKE) and NMSS vis email. </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. +
06:00:00, 3 January 2019 +
53,814 +
12:15:00, 4 January 2019 +
06:00:00, 3 January 2019 +
EN Revision Text: MEDICAL EVENT - Y-90 THE … EN Revision Text: MEDICAL EVENT - Y-90 THERASPHERES ADMINISTERED TO THE WRONG LIVER SEGMENT</br>A medical event occurred on 1/3/2019 at Washington University in St. Louis. The patient treatment plan called for 1.06 GBq of Y-90 TheraSpheres to be administered to Segments 6 and 7 of the patient's liver. However, 1.02 GBq of Y-90 TheraSpheres were administered to Segments 5 and 8 of the patient's liver instead.</br>The patient and the referring physician were notified of the event. Washington University in St. Louis has initiated an investigation of the event.</br>* * * RETRACTION ON 1/14/19 AT 1256 EST FROM MAXWELL AMURAO TO THOMAS KENDZIA * * *</br>The following was received via email from the licensee:</br>As a follow up to the phone call placed today (1/14/19) at 12:56 pm EST, (the licensee radiation safety officer) is writing to retract the report of a event number 53814. The initial report of a suspected medical event with the administration of Y-90 microspheres to a patient was made on 1/4/19 at 12:15 pm EST. After taking the limitations of the imaging software into account, the reviewing team of clinicians have evaluated that the Y-90 microspheres were administered to the correct patient, with the correct dosage and correct route of administration, and in agreement with the Written Directive.</br>Notified R3DO (PELKE) and NMSS vis email. </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. +
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00:00:00, 14 January 2019 +
24-00167-11 +
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12:30:05, 15 January 2019 +
12:15:00, 4 January 2019 +
1.26 d (30.25 hours, 0.18 weeks, 0.0414 months) +
06:00:00, 3 January 2019 +
Missouri + and Washington +
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