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The following report was received from New … The following report was received from New York City via email.</br>Summary: Patient being treated with Y-90 Theraspheres received only 9.5% of a total dose of Y-90. The rest remained in the tubing.</br>Details of the incident: A patient (at the NYC Mount Sinai Medical Center) was being treated with Y-90 Theraspheres. The target organ was the liver. Due to the need to access the liver via the radial artery in the arm, the angiocatheter was too short to connect to the delivery apparatus directly, thus requiring an extension tubing. The entire contents of the dose vial was emptied and flushed 4 times. It was discovered by the radiochemist (after the patient's treatment) that only 9.5% of the total dose was delivered. The rest remained in the extension tubing. (The prescribed dose was 120 Gy and the delivered dose was 11.4 Gy).</br>Corrective action taken by the facility: More time will be taken to reposition the patient proximal to the delivery system. Also, the use of extension tubing will be avoided if possible. Policy and procedures will be updated to include when the use of extension tubing is allowed.</br>Causes/Contributing Factors: Inadequate policy and procedures.</br>RSO's review summarization: The failure to administer the correct dose to the patient was due to the addition of extension tubing. Because of the additional 40cm of IV tubing, which was used to bridge the distance between the Y-90 delivery system and the radial catheter, the intended dose remained lodged inside the extension. The additional flush used was not enough to push the dose through to the target.</br>The dose deviation was greater than 50%, and no additional patient testing or extended hospital stay was required. The patient and referring physician have been notified.</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. +
04:00:00, 20 September 2012 +
49,266 +
13:54:00, 12 August 2013 +
04:00:00, 20 September 2012 +
The following report was received from New … The following report was received from New York City via email.</br>Summary: Patient being treated with Y-90 Theraspheres received only 9.5% of a total dose of Y-90. The rest remained in the tubing.</br>Details of the incident: A patient (at the NYC Mount Sinai Medical Center) was being treated with Y-90 Theraspheres. The target organ was the liver. Due to the need to access the liver via the radial artery in the arm, the angiocatheter was too short to connect to the delivery apparatus directly, thus requiring an extension tubing. The entire contents of the dose vial was emptied and flushed 4 times. It was discovered by the radiochemist (after the patient's treatment) that only 9.5% of the total dose was delivered. The rest remained in the extension tubing. (The prescribed dose was 120 Gy and the delivered dose was 11.4 Gy).</br>Corrective action taken by the facility: More time will be taken to reposition the patient proximal to the delivery system. Also, the use of extension tubing will be avoided if possible. Policy and procedures will be updated to include when the use of extension tubing is allowed.</br>Causes/Contributing Factors: Inadequate policy and procedures.</br>RSO's review summarization: The failure to administer the correct dose to the patient was due to the addition of extension tubing. Because of the additional 40cm of IV tubing, which was used to bridge the distance between the Y-90 delivery system and the radial catheter, the intended dose remained lodged inside the extension. The additional flush used was not enough to push the dose through to the target.</br>The dose deviation was greater than 50%, and no additional patient testing or extended hospital stay was required. The patient and referring physician have been notified.</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, 12 August 2013 +
Not Provided +
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02:00:14, 2 March 2018 +
13:54:00, 12 August 2013 +
326.413 d (7,833.9 hours, 46.63 weeks, 10.731 months) +
04:00:00, 20 September 2012 +
Agreement State - Patient Being Treated with Y-90 Theraspheres Received Only 9.5% of a Total Dose +
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