ENS Event | |
|---|---|
04:00 Aug 16, 2019 | |
| Title | Agreement State Report - Patient Under-Dosage |
| Event Description | The following was received via fax:
On August 16, 2019, a patient underwent a Y-90 SIR-Sphere treatment. The treatment plan was for 2 administrations of Y-90. The first administration was delivered without incident. The second administration was to be a total dosage of 12.27 mCi delivered to the right lobe of the liver. During this second administration, it was observed that the team had backflow into the administration vile. The administration was immediately halted, and the team took readings to ascertain the amount of material delivered. It was estimated that only 28 percent of the dose was delivered to the patient. The patient was verbally informed the day of the event. The referring physician was left a voicemail on the day of the event, however further attempts will be made to contact him directly. Event Report ID No.: PA190019 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 | |
|---|---|
| Thomas Jefferson University Hospitals Philadelphia, Pennsylvania (NRC Region 1) | |
| License number: | PA-0130 |
| Organization: | Pa Bureau Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+82.28 h3.428 days <br />0.49 weeks <br />0.113 months <br />) | |
| Opened: | John Chippo 14:17 Aug 19, 2019 |
| NRC Officer: | Jeffrey Whited |
| Last Updated: | Aug 19, 2019 |
| 54230 - NRC Website | |
Thomas Jefferson University Hospitals with Agreement State | |
WEEKMONTHYEARENS 542302019-08-16T04:00:00016 August 2019 04:00:00
[Table view]Agreement State Agreement State Report - Patient Under-Dosage ENS 497622014-01-22T05:00:00022 January 2014 05:00:00 Agreement State Pennsylvania Agreement State Report - Medical Underdose 2019-08-16T04:00:00 | |