ENS 53377
ENS Event | |
|---|---|
18:30 Jan 23, 2018 | |
| Title | Agreement State Report - Patient Received Dose Less than Prescribed Dose |
| Event Description | The following information was obtained from the state of Washington via email:
Swedish Medical Center (SMC) reported that a patient prescribed to receive 725 MBq (19.59 mCi) of Y-90 microspheres (Sirtex Medical model SIR-Spheres) to the left lobe of the liver, only received 370 MBq (10 mCi). SMC planned a two-artery feed, using 360 MBq (9.73 mCi) per artery per sub lobe. The written directive called for a total of 725 MBq (19.59 mCi) split into two doses. The certified nuclear medicine technologist who drew the dose did not properly review the written directive's instruction to split the total dose into two doses. Instead, the technologist split 370 MBq (10 mCi) into two doses of 190 and 180 MBq (5.14 and 4.86 mCi), respectively. Prior to patient administration, the radiation oncologist also failed to check the drawn doses prior to injecting them. The incident was identified post-injection when the remaining 360 MBq (9.73 mCi) of the original 725 MBq (19.59 mCi) was discovered. The physicians involved believe that the diminished dose may still provide the treatment sought. They will follow up on the patient in six months and will, if deemed necessary, retreat the liver lesions. The referring physician and patient were informed of the incident. SMC's investigation identified several errors: lack of comprehension regarding the dose draw worksheet, miscommunication and failure to review the written directive prior to correcting a dose, and failure to perform a safety pause and properly review the dose to be administered against the written directive prior to administration. Corrective actions included modifying the dose draw spreadsheet, training the nuclear medicine department with regards to the spreadsheet, and modifying the treatment record sheet to include a formal procedural pause prior to administration. The Washington Department of Health, Office of Radiation Protection, did not anticipate conducting an onsite investigation. NMED Item Number: 180058 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 | |
|---|---|
| Swedish Medical Center Seattle, Washington (NRC Region 4) | |
| License number: | WA-WN-M008-1 |
| Organization: | Wa Office Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+2378.38 h99.099 days <br />14.157 weeks <br />3.258 months <br />) | |
| Opened: | James Killingbeck 19:53 May 2, 2018 |
| NRC Officer: | Dong Park |
| Last Updated: | May 2, 2018 |
| 53377 - NRC Website | |
Swedish Medical Center with Agreement State | |
WEEKMONTHYEARENS 569302024-01-19T20:00:00019 January 2024 20:00:00
[Table view]Agreement State Y-90 Microsphere Misadministration ENS 540222019-04-23T07:00:00023 April 2019 07:00:00 Agreement State Washington Agreement State Report - Lost and Found Radioactive Material ENS 538042018-12-19T08:00:00019 December 2018 08:00:00 Agreement State En Revision Imported Date 1/18/2019 ENS 537942018-12-15T07:00:00015 December 2018 07:00:00 Agreement State Agreement State Report - Medical Misadministration ENS 533772018-01-23T18:30:00023 January 2018 18:30:00 Agreement State Agreement State Report - Patient Received Dose Less than Prescribed Dose ENS 435352007-07-17T17:00:00017 July 2007 17:00:00 Agreement State Agreement State Report - Six Lost Palladium - 103 Seeds ENS 415012005-03-17T20:00:00017 March 2005 20:00:00 Agreement State Argeement State Medical Event ENS 410782004-09-24T07:00:00024 September 2004 07:00:00 Agreement State Agreement State Report ENS 403372003-11-17T08:00:00017 November 2003 08:00:00 Agreement State Patient Received an Overdose During a Brachytherapy Procedure 2024-01-19T20:00:00 | |