ENS Event | |
|---|---|
04:00 Aug 5, 2009 | |
| Title | Agreement State Report - Medical Dose Different than Prescribed |
| Event Description | During an embolization procedure delivering Yttrium-90 spheres to the liver an interruption occurred resulting in only 35 Gy of the 52 Gy prescribed dose being delivered. The interruption was due to unexpected contamination due to a leaking septum v-vial Contamination was contained in a container and did not enter the patient. The patient and referring physician will be notified.
GA report number: 2009-09i. 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 | |
|---|---|
| Emory University Atlanta, Georgia (NRC Region 1) | |
| License number: | GA 153-1 |
| Organization: | Georgia Radioactive Material Pgm |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+10.13 h0.422 days <br />0.0603 weeks <br />0.0139 months <br />) | |
| Opened: | Irene Bennett 14:08 Aug 5, 2009 |
| NRC Officer: | Pete Snyder |
| Last Updated: | Aug 5, 2009 |
| 45246 - NRC Website | |
Emory University with Agreement State | |
WEEKMONTHYEARENS 569462024-02-01T05:00:0001 February 2024 05:00:00
[Table view]Agreement State Lost Source ENS 560072022-07-20T04:00:00020 July 2022 04:00:00 Agreement State Dose Misadministration ENS 558502022-04-11T04:00:00011 April 2022 04:00:00 Agreement State Lost/Missing Source ENS 549742020-10-29T04:00:00029 October 2020 04:00:00 Agreement State Dose Delivered Differs by Greater than 20 Percent ENS 549672020-10-23T04:00:00023 October 2020 04:00:00 Agreement State Dose Delivered Differs by Greater than 20 Percent ENS 534682018-06-21T04:00:00021 June 2018 04:00:00 Agreement State En Revision Imported Date 7/3/2018 ENS 529792017-08-24T04:00:00024 August 2017 04:00:00 Agreement State Agreement State Report - Dose Delivered 20% Greater than Prescribed and Greater than 50 Rem to the Targeted Area ENS 499172014-02-27T04:00:00027 February 2014 04:00:00 Agreement State Agreement State Report - Yttrium 90 Medical Event ENS 484412011-05-24T04:00:00024 May 2011 04:00:00 Agreement State Agreement State Report - Y-90 Therasphere Spill ENS 452462009-08-05T04:00:0005 August 2009 04:00:00 Agreement State Agreement State Report - Medical Dose Different than Prescribed ENS 443312008-05-31T04:00:00031 May 2008 04:00:00 Agreement State Agreement State - Possible Overexposure 2024-02-01T05:00:00 | |