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A medical event occurred at 12:04 pm on Ju … A medical event occurred at 12:04 pm on July 2, 2008. The licensee is Baylor University Medical Center, License Number L01290.</br> </br>The unsealed source is Y-90 Therasphere microspheres for treatment of liver cancer. The prescribed dose is 100 Gray, and the prescribed dose range is from 95 Gray to 105 Gray.</br> </br>The activity of the Y-90 Therasphere microspheres was verified at 9:13 am - with 13.4 mCi in the vial - using the dose calibrator as per the manufacturer instructions. However when the dose was delivered the 3 way stop-cock was set erroneously and almost the entire dose was collected in the vent vial. Attempts to recover and deliver the misdirected dose was very limited. Post-administration, the residual activity in the original dose vial, the vent vial, and contaminated effects (catheter line, tubing, needles, towels, gauze pads, etc) totaled 12.046 mCi normalized to the 9:13 am verification time. Therefore, the estimated administered activity was approximately 1.3 mCi, administered on 2-July-2008 at 12:04 pm. This translates to approximately 8.7 Gray delivered to the treatment site (Liver Tumor).</br> </br>Essentially only 8.7% of the prescribed dose was delivered. The licensee is continuing the investigation.</br>Texas event report I-8522</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. +
17:04:00, 2 July 2008 +
44,335 +
14:11:00, 3 July 2008 +
17:04:00, 2 July 2008 +
A medical event occurred at 12:04 pm on Ju … A medical event occurred at 12:04 pm on July 2, 2008. The licensee is Baylor University Medical Center, License Number L01290.</br> </br>The unsealed source is Y-90 Therasphere microspheres for treatment of liver cancer. The prescribed dose is 100 Gray, and the prescribed dose range is from 95 Gray to 105 Gray.</br> </br>The activity of the Y-90 Therasphere microspheres was verified at 9:13 am - with 13.4 mCi in the vial - using the dose calibrator as per the manufacturer instructions. However when the dose was delivered the 3 way stop-cock was set erroneously and almost the entire dose was collected in the vent vial. Attempts to recover and deliver the misdirected dose was very limited. Post-administration, the residual activity in the original dose vial, the vent vial, and contaminated effects (catheter line, tubing, needles, towels, gauze pads, etc) totaled 12.046 mCi normalized to the 9:13 am verification time. Therefore, the estimated administered activity was approximately 1.3 mCi, administered on 2-July-2008 at 12:04 pm. This translates to approximately 8.7 Gray delivered to the treatment site (Liver Tumor).</br> </br>Essentially only 8.7% of the prescribed dose was delivered. The licensee is continuing the investigation.</br>Texas event report I-8522</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, 3 July 2008 +
L01290 +
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02:14:03, 2 March 2018 +
14:11:00, 3 July 2008 +
0.88 d (21.12 hours, 0.126 weeks, 0.0289 months) +
17:04:00, 2 July 2008 +
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