ENS Event | |
|---|---|
08:00 Jan 15, 2018 | |
| Title | Agreement State Report - Delivered Dosage Different from Prescribed |
| Event Description | On January 15, 2018 a medical event occurred at the licensed facility in which a patient received a prescribed dose less than 80 percent of the target dose to the liver. The dose was delivered via Y-90 microspheres.
The State will investigate this medical event.
On January 15, 2018, a patient was prescribed a dose of 130 Gy (2.789 GBq) for the left lobe of the liver involving two dose vials of Y-90 MDS Nordion TheraSphere microspheres. The first dose vial was administered without issue. The second dose vial was then primed and prepped as normal, however, a train of bubbles was noted in the line between the dose vial and the patient prior to administration. Due to the proximity of gastric artery relative to point of administration and the possibility that the bubbles could cause the flow to reflux into this artery (which could permanently damage the stomach), the AU [Authorized User] determined the best course of action was not to administer the second dose vial. The therapy procedure was then halted and rescheduled to complete on Thursday, January 18th. The administered dose was 84.9 Gy (1.760 GBq) to the left lobe of the liver. The dose was therefore 65% of the prescribed dose, a 35% difference. The difference between the prescribed and administered dose to the liver is 45.1 Gy (4510 rem). Therefore, the dose administered exceeds +/- 20% of prescribed dose and differs from the prescribed dose by more than 50 rem to an organ (liver). The referring physician has been notified as well as the patient. This event was reported to the Oregon Agreement State program on January 16, 2018. The licensee has removed all Y-90 therapy tubing sets from the same lot number for return and analysis by the vendor. Tubing sets from a different lot number were provided to interventional radiology for future cases. Notified R4DO (Proulx) and NMSS Events Resource (email). State Event Report ID No.: OR-18-0001 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 | |
|---|---|
| Kaiser Foundation Hospital Portland, Oregon (NRC Region 4) | |
| License number: | ORE-90464 |
| Organization: | Or Dept Of Health Rad Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+56.75 h2.365 days <br />0.338 weeks <br />0.0777 months <br />) | |
| Opened: | Daryl Leon 16:45 Jan 17, 2018 |
| NRC Officer: | David Aird |
| Last Updated: | Jan 19, 2018 |
| 53171 - NRC Website | |
Kaiser Foundation Hospital with Agreement State | |
WEEKMONTHYEARENS 531712018-01-15T08:00:00015 January 2018 08:00:00
[Table view]Agreement State Agreement State Report - Delivered Dosage Different from Prescribed 2018-01-15T08:00:00 | |