ENS 54876: Difference between revisions
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{{ENS notification | {{ENS notification | ||
| event number = 54876 | | event number = 54876 | ||
| facility = | | facility = | ||
| Organization = Ohio Bureau Of Radiation Protection | | Organization = Ohio Bureau Of Radiation Protection | ||
| license number = 02110180077 | | license number = 02110180077 | ||
| Line 10: | Line 10: | ||
| utype = | | utype = | ||
| cfr = Agreement State | | cfr = Agreement State | ||
| emergency class = | | emergency class = Non Emergency | ||
| notification date = 09/03/2020 11:13 | | notification date = 09/03/2020 11:13 | ||
| notification by = Michael J. Rubadue | | notification by = Michael J. Rubadue | ||
| Line 16: | Line 16: | ||
| event date = 08/27/2020 00:00 EDT | | event date = 08/27/2020 00:00 EDT | ||
| last update date = 09/03/2020 | | last update date = 09/03/2020 | ||
| title = Agreement State Report - | | title = <Td Align="Left" Scope="Row">Agreement State Report - Incorrect Dose Delivered to Patient | ||
| event text = The following was received from the Ohio Department of Health: | | event text = The following was received from the Ohio Department of Health: | ||
The licensee tried to perform a split dose procedure on the right lobe anterior and right lobe posterior portion of a patient's liver. | The licensee tried to perform a split dose procedure on the right lobe anterior and right lobe posterior portion of a patient's liver. | ||
The prescribed dose was 60 mCi Y-90 Theraspheres (approximately 150 Gy) for each site. | The prescribed dose was 60 mCi Y-90 Theraspheres (approximately 150 Gy) for each site. The posterior was treated first and then the catheter was moved to the anterior position. Post treatment scans of the patient indicated the posterior received 20 mCi (35 Gy) and the anterior received 100 mCi (180 Gy). The physician believes the catheter slipped after initial placement, resulting in an overdose to the anterior and underdose to the posterior. | ||
The licensee will no longer conduct spilt dose procedures. | The licensee will no longer conduct spilt dose procedures. | ||
Ohio Item Number: | Ohio Item Number: OH200006 | ||
A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. | 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/2020/20200914en.html#en54876 | | URL = https://www.nrc.gov/reading-rm/doc-collections/event-status/event/2020/20200914en.html#en54876 | ||
}} | }} | ||
{{ENS-Nav}} | {{ENS-Nav}} | ||
Latest revision as of 12:21, 15 January 2021
| Where | |
|---|---|
| Ohio Bureau Of Radiation Protection Cleveland, Ohio (NRC Region 3) | |
| License number: | 02110180077 |
| Organization: | Ohio Bureau Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+175.22 h7.301 days <br />1.043 weeks <br />0.24 months <br />) | |
| Opened: | Michael J. Rubadue 11:13 Sep 3, 2020 |
| NRC Officer: | Thomas Herrity |
| Last Updated: | Sep 3, 2020 |
| 54876 - NRC Website | |