ENS 54672: Difference between revisions
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On April 16, 2020, a patient received 11.5 percent of the prescribed dose of Y-90 TheraSphere therapy to the left liver. It is believed that the delivery device malfunctioned as the technician experienced increased pressure in the line when pushing the TheraSphere into the caster. The therapy was aborted after a few failed attempts. The intended dose was 97.3 milliCuries of Y-90. The patient is aware and will be returning for the remainder of the dose. The licensee contacted the vendor who will discard the malfunctioned device. | On April 16, 2020, a patient received 11.5 percent of the prescribed dose of Y-90 TheraSphere therapy to the left liver. It is believed that the delivery device malfunctioned as the technician experienced increased pressure in the line when pushing the TheraSphere into the caster. The therapy was aborted after a few failed attempts. The intended dose was 97.3 milliCuries of Y-90. The patient is aware and will be returning for the remainder of the dose. The licensee contacted the vendor who will discard the malfunctioned device. | ||
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. | 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. | ||
| URL = https://www.nrc.gov/reading-rm/doc-collections/event-status/event/2020/ | | URL = https://www.nrc.gov/reading-rm/doc-collections/event-status/event/2020/20200428en.html#en54672 | ||
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Revision as of 07:30, 28 April 2020
| Where | |
|---|---|
| Christiana Care Health Services Wilmington, Delaware (NRC Region 1) | |
| License number: | 07-12153-02 |
| Organization: | Christiana Care Health Services |
| Reporting | |
| 10 CFR 35.3045(a)(1) | |
| Time - Person (Reporting Time:+32.62 h1.359 days <br />0.194 weeks <br />0.0447 months <br />) | |
| Opened: | Karol Wen 12:37 Apr 17, 2020 |
| NRC Officer: | Caty Nolan |
| Last Updated: | Apr 17, 2020 |
| 54672 - NRC Website | |