ENS Event | |
|---|---|
04:00 Jun 22, 2021 | |
| Title | Underdose to Patient |
| Event Description | The following was received from the state of Ohio via email:
Event occurred on 6/22/21. The patient was scheduled for therapy with Y-90 Sir-Spheres. The prescribed dose was 4389 rem. [However, they] administered only 3336 rem, or 76 percent (-24 percent) of the prescribed dose. During the infusion of the Sir-Sphere particles, the infusion catheter became clogged due to the high volume of particles. The catheter was removed, a new catheter placed and used for the infusion of the remaining particles. Stasis was not reached, there was not a patient event, and the estimated difference in dose to the patient exceeds 50 rem to the liver. There were no negative effect to the individual patient, no additional treatment is necessary as a result of this occurrence (administered therapy is sufficient), and no further actions are necessary to prevent recurrence. The physician notified the patient and [their] personal representative of the event, post therapy on 6/22/2021. Ohio Item Number: OH210005 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 | |
|---|---|
| Christ Hospital, Cincinnati Cincinnati, Ohio (NRC Region 3) | |
| License number: | 02120310008 |
| Organization: | Ohio Department Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+53.48 h2.228 days <br />0.318 weeks <br />0.0733 months <br />) | |
| Opened: | Micheal Snee 09:29 Jun 24, 2021 |
| NRC Officer: | Thomas Herrity |
| Last Updated: | Jun 24, 2021 |
| 55324 - NRC Website | |
Christ Hospital, Cincinnati with Agreement State | |
WEEKMONTHYEARENS 553242021-06-22T04:00:00022 June 2021 04:00:00
[Table view]Agreement State Underdose to Patient 2021-06-22T04:00:00 | |