ENS Event | |
|---|---|
04:00 Aug 18, 2020 | |
| Title | Agreement State Report - Patient Underdose |
| Event Description | The following report was received from the Ohio Department of Health via email.
On August 14, 2020, the licensee attempted to treat a patient with Y-90 TheraSphere microspheres. Under the guidance of the manufacturer's representative, the AU [Authorized User] performed pre-patient checks on the device, including tubing patency check. After the infusion was started it became apparent the patient was not receiving the dose, and the licensee was unable to clear the blockage in the tubing. The procedure was terminated and the patient and referring physician were notified. Approximately 93% of the activity remained in the device. Static imaging was performed on the patient to determine the dose received. There was no measurable activity in the patient. Ohio Event No.: OH200004 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 Department Of Health Columbus, Ohio (NRC Region 3) | |
| License number: | OH-02120250070 |
| Organization: | Ohio Department Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+9.22 h0.384 days <br />0.0549 weeks <br />0.0126 months <br />) | |
| Opened: | Michael Rubadue 13:13 Aug 18, 2020 |
| NRC Officer: | Michael Bloodgood |
| Last Updated: | Aug 18, 2020 |
| 54840 - NRC Website | |
Ohio Department Of Health with Agreement State | |
WEEKMONTHYEARENS 548402020-08-18T04:00:00018 August 2020 04:00:00
[Table view]Agreement State Agreement State Report - Patient Underdose 2020-08-18T04:00:00 | |