ENS Event | |
|---|---|
06:00 Feb 28, 2019 | |
| Title | |
| Event Description | The following report was received from the Kentucky Department of Public Health via email:
The University of Kentucky RSO [Radiation Safety Officer] reports a patent delivery system failed to deliver part of a TheraSphere Y-90 treatment on February 28, 2019. A patient written directive indicated a prescribed dose of 208 Gy. The patient only received 145 Gy. The RSO indicated the first vial of Y-90 was administered without difficulty. The second vial failed to empty into the administration catheter. Calls were placed to the drug representative and unsuccessful attempts made to administer the remainder of the dose. Patient treatment was stopped with only partial dose delivery. At the time of the report, March 1, 2019, the University is establishing the reason for the administration failure. The patient had been notified and the physician and referring physician are being notified. The university plans an update in 15 days. Kentucky Event Report ID No.: Ky190002. 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 | |
|---|---|
| University Of Kentucky (Hospital) Lexington, Kentucky (NRC Region 1) | |
| License number: | 202-049-22 |
| Organization: | Kentucky Dept Of Radiation Control |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+31.88 h1.328 days <br />0.19 weeks <br />0.0437 months <br />) | |
| Opened: | Angela Wilbers 13:53 Mar 1, 2019 |
| NRC Officer: | Caty Nolan |
| Last Updated: | Mar 1, 2019 |
| 53904 - NRC Website | |
University Of Kentucky (Hospital) with Agreement State | |
WEEKMONTHYEARENS 539042019-02-28T06:00:00028 February 2019 06:00:00
[Table view]Agreement State Agreement State Report - Underdose of Therasphere Y-90 Treatment 2019-02-28T06:00:00 | |