ENS 50433: Difference between revisions
Jump to navigation
Jump to search
StriderTol (talk | contribs) (Created page by program invented by Mark Hawes) |
StriderTol (talk | contribs) (Created page by program invented by StriderTol) |
||
| Line 16: | Line 16: | ||
| event date = 09/04/2014 EDT | | event date = 09/04/2014 EDT | ||
| last update date = 09/08/2014 | | last update date = 09/08/2014 | ||
| title = Agreement State Report - Medical Event Due | | title = Agreement State Report - Medical Event Due to Misadministration of Y-90 Theraspheres | ||
| event text = The following information was received via email: | | event text = The following information was received via email: | ||
A Y-90 TheraSphere liver therapy procedure resulted in delivered doses to the liver and lungs that differed from the prescribed dose. The revised Lung Shunt Fraction (LSF) value was used to recalculate the actual radiation dose to lungs and LT liver lobe. The results are that the lungs received 34.5 Gy (instead of 3.7 Gy) and the LT liver lobe received 67 Gy (instead of 117 Gy). Also, it is calculated that the LT liver lobe was implanted with a Y-90 activity dose of 0.82 GBq (22.2 mCi) while the lungs received a Y-90 activity dose of 0.69 GBq (18.64 mCi) since the patient was implanted with 1.50 GBq (40.53 mCi) of Y-90. The patient's family was notified. UVA staff are meeting to analyze the root cause of the event. RMP [Virginia Radioactive Materials Program] staff will review UVA's findings and determine what further actions are necessary. | A Y-90 TheraSphere liver therapy procedure resulted in delivered doses to the liver and lungs that differed from the prescribed dose. The revised Lung Shunt Fraction (LSF) value was used to recalculate the actual radiation dose to lungs and LT liver lobe. The results are that the lungs received 34.5 Gy (instead of 3.7 Gy) and the LT liver lobe received 67 Gy (instead of 117 Gy). Also, it is calculated that the LT liver lobe was implanted with a Y-90 activity dose of 0.82 GBq (22.2 mCi) while the lungs received a Y-90 activity dose of 0.69 GBq (18.64 mCi) since the patient was implanted with 1.50 GBq (40.53 mCi) of Y-90. The patient's family was notified. UVA staff are meeting to analyze the root cause of the event. RMP [Virginia Radioactive Materials Program] staff will review UVA's findings and determine what further actions are necessary. | ||
Latest revision as of 20:49, 1 March 2018
| Where | |
|---|---|
| University Of Virginia Charlottesville, Virginia (NRC Region 1) | |
| License number: | 540-248-1 |
| Organization: | Virginia Rad Materials Program |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+108.62 h4.526 days <br />0.647 weeks <br />0.149 months <br />) | |
| Opened: | Mike Welling 16:37 Sep 8, 2014 |
| NRC Officer: | Donald Norwood |
| Last Updated: | Sep 8, 2014 |
| 50433 - NRC Website
| |