ENS 52473
ENS Event | |
|---|---|
05:00 Dec 29, 2016 | |
| Title | Agreement State Report - Medical Event |
| Event Description | The following report was received via fax:
We [New York State Department of Health] were informed on January 3, 2017 that on December 29, 2016, a 61 year old female patient was to receive SIR spheres Y90 infusion to 2 lesions in her liver at a hospital. The small lesion was to receive 10% and the large lesion was to receive 90% of 24.53 mCi Y90. Staff prepared 2 vials according to the Written Directive, and labeled each vial shield. When the first infusion, for the smaller lesion, was called for, a technologist took one vial to the IR room. She believed she had the correct 10% marked vial. She removed the top of the shielded container holding the vial, then she left the IR suite. The patient was injected. When the second infusion, for the large lesion, was called for, the same technologist took the second shielded vial from the hot lab and noticed that it was the one marked with the 10% label. It appears that the vials themselves were not labeled, only the lids of the containers holding the vials were labeled. Once they realized what had happened, they decided to infuse the second larger lesion with what was left over in the first vial as well as what was in the second vial. The licensee has not yet provided the values for the actual administered dose to each lesion. However, it appears clear that the discrepancy in the prescribed activity and administered activity for each lesion meets the reportable medical event criteria. [The licensee's] initial report stated there is no harm to the patient. A full report, including the actual activity delivered and a root cause analysis is required/pending. 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 | |
|---|---|
| Not Provided Not Provided, New York (NRC Region 1) | |
| Organization: | New York State Dept. Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+155.05 h6.46 days <br />0.923 weeks <br />0.212 months <br />) | |
| Opened: | Not Provided 16:03 Jan 4, 2017 |
| NRC Officer: | Mark Abramovitz |
| Last Updated: | Jan 4, 2017 |
| 52473 - NRC Website | |
Not Provided with Agreement State | |
WEEKMONTHYEARENS 550062020-11-23T04:00:00023 November 2020 04:00:00
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