ENS 57110: Difference between revisions
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| NRC officer = Adam Koziol | | NRC officer = Adam Koziol | ||
| event date = 05/06/2024 11:00 CDT | | event date = 05/06/2024 11:00 CDT | ||
| last update date = | | last update date = 07/09/2024 | ||
| title = Medical Event - Y-90 Overdose | | title = Medical Event - Y-90 Overdose | ||
| event text = The following information was provided by the licensee via telephone: | | event text = The following information was provided by the licensee via telephone: | ||
A patient had a written directive to receive 90 Gy of Y-90 TheraSpheres to the liver. When the order was entered into the system, the wrong activity was entered. The higher activity of 360 Gy Y-90 TheraSpheres was then administered to the patient. The calculated dose to the liver may exceed 50 rem. | A patient had a written directive to receive 90 Gy of Y-90 TheraSpheres to the liver. When the order was entered into the system, the wrong activity was entered. The higher activity of 360 Gy Y-90 TheraSpheres was then administered to the patient. The calculated dose to the liver may exceed 50 rem. | ||
The patient and referring physician were informed. No health effect or permanent functional damage is expected. | The patient and referring physician were informed. No health effect or permanent functional damage is expected. | ||
A Medical Event may indicate potential problems in a medical facility | 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/2024/ | * * * UPDATE ON 7/9/24 AT 1644 EDT FROM JAMIE EISENBERG TO KAREN COTTON * * * | ||
The following summary was provided by the licensee via telephone: | |||
After further assessment of the event, it was discovered that the patient also received an unintended dose of 360 Gy Y-90 TheraSpheres to the lungs. No health effect or permanent functional damage is expected. | |||
Notified R3DO (Nguyen), NMSS Events Notification (email), NMSS Regional Coordinator (Sun) | |||
| URL = https://www.nrc.gov/reading-rm/doc-collections/event-status/event/2024/20240710en.html#en57110 | |||
}} | }} | ||
{{ENS-Nav}} | {{ENS-Nav}} | ||
Revision as of 07:20, 10 July 2024
| Where | |
|---|---|
| Saint Francis Medical Center Cape Girardeau, Missouri (NRC Region 3) | |
| License number: | 24-00158-03 |
| Organization: | Saint Francis Medical Center |
| Reporting | |
| 10 CFR 35.3045(a)(1) | |
| Time - Person (Reporting Time:+22.93 h0.955 days <br />0.136 weeks <br />0.0314 months <br />) | |
| Opened: | Jamie Eisenberg 14:56 May 7, 2024 |
| NRC Officer: | Adam Koziol |
| Last Updated: | Jul 9, 2024 |
| 57110 - NRC Website | |