ENS Event | |
|---|---|
05:00 Jun 4, 2015 | |
| Title | Agreement State Report - Medical Treatment Incorrect Dose |
| Event Description | The following was received via email:
On June 5, 2015, the Arkansas Department of Health (ADH) received notification from the licensee's Radiation Safety Officer (RSO) of a possible medical event that occurred during an Yttrium-90 TheraSpheres procedure on June 4, 2015. The licensee has not completed the investigation and has provided limited information to determine if the procedure constituted a medical event. The patient was treated with Y-90 TheraSpheres. The written directive prescribed a dose of 114 Gy, but received a dose of 18.3 Gy. Preliminary findings seem to indicate that an incorrect dose may have been administered to the patient. The patient and referring physician have been notified. The licensee and ADH are continuing to investigate this event. ADH considers this event to be opened and will provide more information as it becomes available. 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. ARKANSAS EVENT #2015-005
The following information was received from the State of Arkansas via email: The Arkansas Department of Health (ADH) is requesting the retraction of NRC Event Number [51130]. ADH received a report from the licensee dated June 18, 2015. The report and investigation conducted by the licensee determined that this event did not qualify as a reportable medical event. A review of the written directive indicated that the radiation dose that was prescribed by the authorized user was delivered to the patient. The authorized user had intended to prescribe 114 Gray. This was confirmed by ADH after further review of the documentation obtained during the on-site investigation. The patient completed this treatment on June 29, 2015. The licensee has implemented revisions in the treatment procedures for further safety improvements. The ADH considers this event to be closed. Notified the R4DO (Haire) and NMSS Events Notification Group via email. |
| Where | |
|---|---|
| University Of Arkansas For Medical Sciences Little Rock, Arkansas (NRC Region 4) | |
| License number: | ARK-0001-0211 |
| Organization: | Arkansas Department Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+34.37 h1.432 days <br />0.205 weeks <br />0.0471 months <br />) | |
| Opened: | Jared Thompson 15:22 Jun 5, 2015 |
| NRC Officer: | Richard Smith |
| Last Updated: | Jul 6, 2015 |
| 51130 - NRC Website | |
University Of Arkansas For Medical Sciences with Agreement State | |
WEEKMONTHYEARENS 571782024-06-07T05:00:0007 June 2024 05:00:00
[Table view]Agreement State Y-90 Microsphere Underdose ENS 538792019-02-13T13:24:00013 February 2019 13:24:00 Agreement State En Revision Imported Date 6/5/2019 ENS 511302015-06-04T05:00:0004 June 2015 05:00:00 Agreement State Agreement State Report - Medical Treatment Incorrect Dose ENS 467182011-03-16T05:00:00016 March 2011 05:00:00 Agreement State Agreement State Report - Yttrium-90 Microspsheres Administered Dose Less than Prescribed Dose 2024-06-07T05:00:00 | |