ENS 48286: Difference between revisions

ENS 48286 +/-
Where
	University Of Pittsburgh ; Pittsburgh, Pennsylvania (NRC Region 1)
License number:	PA-0190
Organization:	Pa Bureau Of Radiation Protection
Reporting
	Agreement State
Time - Person (Reporting Time:+34.48 h1.437 days <br />0.205 weeks <br />0.0472 months <br />)
Opened:	Joseph Melnic; 14:29 Sep 7, 2012
NRC Officer:	Pete Snyder
Last Updated:	Sep 7, 2012
	48286 - NRC Website
	v • d • e

Latest revision as of 19:15, 24 November 2018

@@ Line 3: / Line 3: @@
 | facility = University Of Pittsburgh
 | Organization = Pa Bureau Of Radiation Protection
-| license number = Pa-0190
+| license number = PA-0190
 | region = 1
 | state = Pennsylvania

v t e ENS Event
04:00 Sep 6, 2012
Title	Agreement State Report - Yttrium-90 Microspheres Administered to the Wrong Treatment Site
Event Description	On September 6, 2012, the [Pennsylvania Department of Environmental Protection, Bureau of Radiation Protection (PADEPBRP)] Central Office received notification via a phone call about this medical event. The patient received an administration of approximately 1.4 millicuries (mCi) of Y-90 microspheres to the wrong treatment site. The intended treatment was to administer approximately 24 mCi to the left lobe of the liver through three different arteries. During the administration of one of the split doses, the Interventional Radiologist (IR) incorrectly positioned the catheter in the right hepatic artery. A portion of the one split dose was administered to the right lobe of the liver before the IR realized that the catheter was not in the correct artery. Cause of the event: Human Error. Actions: Both the referring physician and the patient have been notified of the medical event. The [PADEPBRP] plans to do a reactive inspection. 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.

v t e Emergency Notification System
University Of Pittsburgh with Agreement State
WEEKMONTHYEAR2023-09-28T04:00:00 [Table view]
[ENS list for University Of Pittsburgh]