The following was received from the state of
Ohio via email:
During a routine inspection an unreported medical event [that occurred in 2019] involving Yttrium-90 'SirSpheres' was discovered. During patient treatment the licensee encountered increasing resistance to the delivery of the microspheres, leading the licensee to believe the patient had reached stasis. After further investigation the licensee determined the cause of the resistance was clogging of the microcatheter. The dose delivered to the patient was 79.2 percent of the prescribed dose. A subsequent treatment was given to the patient to make up for the underdose. At the time the licensee's procedures did not consider this as a reportable event. The reportable event procedures have been updated.
Ohio Item Number: OH210001
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.