ENS Event | |
|---|---|
07:00 Nov 3, 2011 | |
| Title | Agreement State Report- Delivered Patient Dose Different than Prescribed |
| Event Description | The following information was received by email:
Based on protocol, a dose of 120 Gy (1.79 GBq) was prescribed. Upon completion of the treatment, survey of the Nalgene waste container measured higher than expected. Ensuing calculations resulted in dose delivered to be 85 Gy (1.24 GBq); greater than 20% variation from prescribed dose. All drapes, towels, etc were surveyed with no evidence of radioactivity present, therefore assuring no contamination present. Contents of the waste container were measured separately to locate the source of residual activity. The readings indicated minimal activity in the Y -90 vial; readings of the patient delivery microcatheter were indicative of residual microspheres. The treatment protocol was followed with no variations of procedure. As is typical, 3 saline flushes were made of the catheter including several vigorous flushes to dislodge any microspheres as recommended by Nordion, the product manufacturer. No high pressure was detected at any point during infusion which would trigger the pressure valve and deliver saline in the overflow vial. There was no build up of particles in the hub of the delivery catheters as inspected throughout the procedure. Measurements over the length of the catheter revealed greatest activity in the proximal portion of the catheter with little-to-no activity in the tip. Nordion has been contacted. In the future, survey of the catheter prior to disconnecting it for disposal may help detect the build-up of particles. Oregon Incident: 11-0037 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 | |
|---|---|
| Legacy Meridian Park Medical Center Tualatin, Oregon (NRC Region 4) | |
| License number: | ORE 90293 |
| Organization: | Or Dept Of Health Rad Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+15631.08 h651.295 days <br />93.042 weeks <br />21.411 months <br />) | |
| Opened: | Kevin Siebert 14:05 Aug 15, 2013 |
| NRC Officer: | Vince Klco |
| Last Updated: | Aug 15, 2013 |
| 49282 - NRC Website | |
Legacy Meridian Park Medical Center with Agreement State | |
WEEKMONTHYEARENS 492822011-11-03T07:00:0003 November 2011 07:00:00
[Table view]Agreement State Agreement State Report- Delivered Patient Dose Different than Prescribed 2011-11-03T07:00:00 | |