ENS Event | |
|---|---|
05:00 Nov 30, 2021 | |
| Title | Underdose of Patient Medical Event |
| Event Description | The following was received from the Commonwealth of Virginia (the Agency) via email:
On December 1, 2021 at 0525 EST, the Virginia Radioactive Materials Program (RMP) received a report from the licensee that a medical event involving Yttrium-90 microspheres occurred on 11/30/2021 (procedure date). According to the written directive, the prescribed dose to the right liver (treatment site) was 27.6 millicuries (mCi). The procedure was interrupted due to the artery spasm, which could not be identified before the treatment began and as a result, only 14.5 mCi of the prescribed dosage was delivered to the treatment site (right liver). The administered dosage was estimated to be 47% less than the prescribed dose. According to the licensee's preliminary report, no healthy tissue or organ other than the treatment site was exposed because of this event and the patient was notified. The RMP will schedule to investigate the event and this report will be updated when the final investigation report is available. Virginia Event Report ID No.: VA210008 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 | |
|---|---|
| Sentara Norfolk General Hospital Norfolk, Virginia (NRC Region 1) | |
| License number: | 710-189-1 |
| Organization: | Virginia Rad Materials Program |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+33.82 h1.409 days <br />0.201 weeks <br />0.0463 months <br />) | |
| Opened: | Asfaw Fenta 14:49 Dec 1, 2021 |
| NRC Officer: | Gerond George |
| Last Updated: | Dec 2, 2021 |
| 55617 - NRC Website | |
Sentara Norfolk General Hospital with Agreement State | |
WEEKMONTHYEARENS 556172021-11-30T05:00:00030 November 2021 05:00:00
[Table view]Agreement State Underdose of Patient Medical Event ENS 500742014-04-24T04:00:00024 April 2014 04:00:00 Agreement State Agreement State Report - Second Scheduled Medical Dose Not Delivered Due to Equipment Failure 2021-11-30T05:00:00 | |