ENS Event | |
|---|---|
04:00 Sep 7, 2018 | |
| Title | Agreement State Report - Administered Dose Lower than Prescribed Dose |
| Event Description | The following information was received from the state of North Carolina via email:
A patient being treated for liver tumors was prescribed to receive 47.6 mCi of Y-90 microspheres, but instead received only 11.9 mCi (about 25 percent of prescribed). The remainder was in the vial as residual. Because this under-dosing was not due to stasis or emergent patient conditions, and the delivered dose was less than 20 percent of that prescribed, this constitutes a reportable medical event according to the 2016 version (9) of the NRC guidance for Y-90 microspheres. Source: Microspheres Radionuclide: Y-90 Manufacturer: Sirtex Medical Model: Sir-Spheres S/N: Aggregate Investigation is pending for the Medical Event. North Carolina Tracking Number: 180039 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. |
| Where | |
|---|---|
| Duke University Medical Center Durham, North Carolina (NRC Region 1) | |
| License number: | 0247-4 |
| Organization: | Nc Div Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+37.73 h1.572 days <br />0.225 weeks <br />0.0517 months <br />) | |
| Opened: | Travis Cartoski 17:44 Sep 8, 2018 |
| NRC Officer: | Andrew Waugh |
| Last Updated: | Sep 8, 2018 |
| 53591 - NRC Website | |
Duke University Medical Center with Agreement State | |
WEEKMONTHYEARENS 562542022-12-01T05:00:0001 December 2022 05:00:00
[Table view]Agreement State Patient Underdose ENS 554092020-08-26T04:00:00026 August 2020 04:00:00 Agreement State Lost IODINE-125 Seed ENS 542822019-09-16T04:00:00016 September 2019 04:00:00 Agreement State Agreement State Report - Medical Event ENS 535912018-09-07T04:00:0007 September 2018 04:00:00 Agreement State Agreement State Report - Administered Dose Lower than Prescribed Dose ENS 525802017-02-24T05:00:00024 February 2017 05:00:00 Agreement State Agreement State Report - Medical Event Due to High Dose ENS 510322014-03-30T04:00:00030 March 2014 04:00:00 Agreement State Agreement State Report - Iodine 125 Seed Left in Patient ENS 463892010-10-22T18:45:00022 October 2010 18:45:00 Agreement State Agreement State Report - Medical Event - Dose Administered in Wrong Location 2022-12-01T05:00:00 | |