ENS 51233: 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 = 07/14/2015 10:30 EDT | | event date = 07/14/2015 10:30 EDT | ||
| last update date = 07/15/2015 | | last update date = 07/15/2015 | ||
| title = Agreement State Report - Dose | | title = Agreement State Report - Dose to Improper Treatment Site | ||
| event text = The following information was received by the State of Ohio via email: | | event text = The following information was received by the State of Ohio via email: | ||
On July 14, 2015, the licensee reported that the intended delivery of Y-90 SirSpheres went to the small bowel instead of the right lobe of the liver during a procedure that morning. The intervention physician felt that the dose delivery was not going where it should be going and discontinued the treatment. Scanning the patient identified that the Y-90 microspheres were delivered to the small bowel. The original prescribed dose to the right lobe of the liver was 78 Gy with 20.5 mCi. The delivered dose of 36 Gy with 7.79 mCi went to the small bowel instead of the liver right lobe. The patient was notified at the time of the event. The interventional physician was the referring physician and AU [Authorized User]. | On July 14, 2015, the licensee reported that the intended delivery of Y-90 SirSpheres went to the small bowel instead of the right lobe of the liver during a procedure that morning. The intervention physician felt that the dose delivery was not going where it should be going and discontinued the treatment. Scanning the patient identified that the Y-90 microspheres were delivered to the small bowel. The original prescribed dose to the right lobe of the liver was 78 Gy with 20.5 mCi. The delivered dose of 36 Gy with 7.79 mCi went to the small bowel instead of the liver right lobe. The patient was notified at the time of the event. The interventional physician was the referring physician and AU [Authorized User]. | ||
Revision as of 21:47, 1 March 2018
| Where | |
|---|---|
| University Hospitals Of Cleveland Cleveland, Ohio (NRC Region 3) | |
| License number: | Oh-0211018007 |
| Organization: | Ohio Bureau Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+20.33 h0.847 days <br />0.121 weeks <br />0.0278 months <br />) | |
| Opened: | Karl Van Ahn 10:50 Jul 15, 2015 |
| NRC Officer: | Vince Klco |
| Last Updated: | Jul 15, 2015 |
| 51233 - NRC Website | |