ENS Event | ||
|---|---|---|
04:00 Aug 27, 2020 | ||
| Title | Agreement State Report - Incorrect Dose Delivered to Patient | |
| Event Description | The following was received from the Ohio Department of Health:
The licensee tried to perform a split dose procedure on the right lobe anterior and right lobe posterior portion of a patient's liver. The prescribed dose was 60 mCi Y-90 Theraspheres (approximately 150 Gy) for each site. The posterior was treated first and then the catheter was moved to the anterior position. Post treatment scans of the patient indicated the posterior received 20 mCi (35 Gy) and the anterior received 100 mCi (180 Gy). The physician believes the catheter slipped after initial placement, resulting in an overdose to the anterior and underdose to the posterior. The licensee will no longer conduct spilt dose procedures. Ohio Item Number: OH200006 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 | |
|---|---|
| Ohio Bureau Of Radiation Protection Cleveland, Ohio (NRC Region 3) | |
| License number: | 02110180077 |
| Organization: | Ohio Bureau Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+175.22 h7.301 days <br />1.043 weeks <br />0.24 months <br />) | |
| Opened: | Michael J. Rubadue 11:13 Sep 3, 2020 |
| NRC Officer: | Thomas Herrity |
| Last Updated: | Sep 3, 2020 |
| 54876 - NRC Website | |
Ohio Bureau of Radiological Health and Safety with Agreement State | |||||
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