ENS 53377: Difference between revisions

v t e ENS Event
18:30 Jan 23, 2018
Title	Agreement State Report - Patient Received Dose Less than Prescribed Dose
Event Description	The following information was obtained from the state of Washington via email: Swedish Medical Center (SMC) reported that a patient prescribed to receive 725 MBq (19.59 mCi) of Y-90 microspheres (Sirtex Medical model SIR-Spheres) to the left lobe of the liver, only received 370 MBq (10 mCi). SMC planned a two-artery feed, using 360 MBq (9.73 mCi) per artery per sub lobe. The written directive called for a total of 725 MBq (19.59 mCi) split into two doses. The certified nuclear medicine technologist who drew the dose did not properly review the written directive's instruction to split the total dose into two doses. Instead, the technologist split 370 MBq (10 mCi) into two doses of 190 and 180 MBq (5.14 and 4.86 mCi), respectively. Prior to patient administration, the radiation oncologist also failed to check the drawn doses prior to injecting them. The incident was identified post-injection when the remaining 360 MBq (9.73 mCi) of the original 725 MBq (19.59 mCi) was discovered. The physicians involved believe that the diminished dose may still provide the treatment sought. They will follow up on the patient in six months and will, if deemed necessary, retreat the liver lesions. The referring physician and patient were informed of the incident. SMC's investigation identified several errors: lack of comprehension regarding the dose draw worksheet, miscommunication and failure to review the written directive prior to correcting a dose, and failure to perform a safety pause and properly review the dose to be administered against the written directive prior to administration. Corrective actions included modifying the dose draw spreadsheet, training the nuclear medicine department with regards to the spreadsheet, and modifying the treatment record sheet to include a formal procedural pause prior to administration. The Washington Department of Health, Office of Radiation Protection, did not anticipate conducting an onsite investigation. NMED Item Number: 180058 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.

ENS 53377 +/-
Where
Swedish Medical Center Seattle, Washington (NRC Region 4)
License number:	WA-WN-M008-1
Organization:	Wa Office Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+2378.38 h99.099 days <br />14.157 weeks <br />3.258 months <br />)
Opened:	James Killingbeck 19:53 May 2, 2018
NRC Officer:	Dong Park
Last Updated:	May 2, 2018
53377 - NRC Website
v • d • e

v t e Emergency Notification System
Swedish Medical Center with Agreement State
WEEKMONTHYEAR2024-01-19T20:00:00 [Table view]
[ENS list for Swedish Medical Center]

@@ Line 3: / Line 3: @@
 | facility = Swedish Medical Center
 | Organization = Wa Office Of Radiation Protection
-| license number = Wa-Wn-M008-1
+| license number = WA-WN-M008-1
 | region = 4
 | state = Washington

ENS 53377: Difference between revisions

Latest revision as of 17:49, 24 November 2018

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ENS 53377: Difference between revisions

Latest revision as of 17:49, 24 November 2018

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