ENS Event | |
|---|---|
05:00 Dec 1, 2022 | |
| Title | Patient Underdose |
| Event Description | The following information was provided by the North Carolina Division of Radiation Protection via email:
The state of North Carolina Radioactive Materials Branch received a report at 1050 EST on December 2, 2022, from Duke University Medical Center (license number: 032-0247-4) of a possible medical event involving a patient receiving Yttrium-90 therapy for treatment of a liver tumor. The treatment had an intended dosage of 91.6 mCi with a delivered dosage of 54.6 mCi resulting in a 40 percent under dosing that did not appear to involve stasis. The patient and the patient's representative were notified at the time of the treatment and the referring physician was notified the morning of December 2, 2022. The licensee is currently investigating the root cause but initially believes it to be caused by equipment failure. The State is currently investigating and will provide more information as it becomes available. NC Incident No.: NC220015 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 | |
|---|---|
| Duke University Medical Center Durham, North Carolina (NRC Region 1) | |
| License number: | 032-0247-4 |
| Organization: | Nc Div Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+33.68 h1.403 days <br />0.2 weeks <br />0.0461 months <br />) | |
| Opened: | Ken Bugaj Jr. 14:41 Dec 2, 2022 |
| NRC Officer: | Bill Gott |
| Last Updated: | Dec 2, 2022 |
| 56254 - NRC Website | |
Duke University Medical Center with Agreement State | |
WEEKMONTHYEARENS 562542022-12-01T05:00:0001 December 2022 05:00:00
[Table view]Agreement State Patient Underdose ENS 554092020-08-26T04:00:00026 August 2020 04:00:00 Agreement State Lost IODINE-125 Seed ENS 542822019-09-16T04:00:00016 September 2019 04:00:00 Agreement State Agreement State Report - Medical Event ENS 535912018-09-07T04:00:0007 September 2018 04:00:00 Agreement State Agreement State Report - Administered Dose Lower than Prescribed Dose ENS 525802017-02-24T05:00:00024 February 2017 05:00:00 Agreement State Agreement State Report - Medical Event Due to High Dose ENS 510322014-03-30T04:00:00030 March 2014 04:00:00 Agreement State Agreement State Report - Iodine 125 Seed Left in Patient ENS 463892010-10-22T18:45:00022 October 2010 18:45:00 Agreement State Agreement State Report - Medical Event - Dose Administered in Wrong Location 2022-12-01T05:00:00 | |