ENS 50647: Difference between revisions
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| event date = 11/07/2014 PST | | event date = 11/07/2014 PST | ||
| last update date = 12/02/2014 | | last update date = 12/02/2014 | ||
| title = Agreement State - Medical Event Involving Underdosage | | title = Agreement State - Medical Event Involving Underdosage to Patient of Y-90 Sir-Spheres | ||
| event text = The following is a synopsis of information received via E-mail: | | event text = The following is a synopsis of information received via E-mail: | ||
The Cedars Sinai Medical Center (CSMC) Radiation Physics Manager (RPM) contacted Los Angeles County Radiation Management (LA County) via telephone to report a potential medical event that had occurred at CSMC. The RPM stated that the event resulted from a dosage administration to the patient of yttrium-90 SIR-Spheres less than that prescribed. LA County requested that a written report be submitted. Per the written report, the treatment plan required administration of 31 milliCuries (mCi) of Y-90 through a catheter via the hepatic artery. During setup, the interventional radiologist (IR) noted a potential air bubble in one of the lines connected to the catheter. The IR disconnected the line and flushed it with solution to clear the air bubble. The IR then activated the SIR-Sphere device without realizing that the line was still disconnected from the catheter. The radioactive material spilled into the sterile 4 inch by 4 inch gauze and drapes on the sterile field. The patient received 13 mCi, which was 42 percent of the prescribed dosage of 31 mCi. The RPM stated that the referring physician and patient were notified and that the patient did not report any side effects as a result of the incorrect dosage administration. Based on CSMC's written report, it was determined that this event required 24-hr notification to the NRC Operations Center. | The Cedars Sinai Medical Center (CSMC) Radiation Physics Manager (RPM) contacted Los Angeles County Radiation Management (LA County) via telephone to report a potential medical event that had occurred at CSMC. The RPM stated that the event resulted from a dosage administration to the patient of yttrium-90 SIR-Spheres less than that prescribed. LA County requested that a written report be submitted. Per the written report, the treatment plan required administration of 31 milliCuries (mCi) of Y-90 through a catheter via the hepatic artery. During setup, the interventional radiologist (IR) noted a potential air bubble in one of the lines connected to the catheter. The IR disconnected the line and flushed it with solution to clear the air bubble. The IR then activated the SIR-Sphere device without realizing that the line was still disconnected from the catheter. The radioactive material spilled into the sterile 4 inch by 4 inch gauze and drapes on the sterile field. The patient received 13 mCi, which was 42 percent of the prescribed dosage of 31 mCi. The RPM stated that the referring physician and patient were notified and that the patient did not report any side effects as a result of the incorrect dosage administration. Based on CSMC's written report, it was determined that this event required 24-hr notification to the NRC Operations Center. | ||
Latest revision as of 21:49, 1 March 2018
| Where | |
|---|---|
| Cedars Sinai Medical Center Los Angeles, California (NRC Region 4) | |
| License number: | 0404-19 |
| Organization: | California Radiation Control Prgm |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+609.25 h25.385 days <br />3.626 weeks <br />0.835 months <br />) | |
| Opened: | Josephine Ortego 17:15 Dec 2, 2014 |
| NRC Officer: | Donald Norwood |
| Last Updated: | Dec 2, 2014 |
| 50647 - NRC Website | |