ENS Event | |
|---|---|
06:00 Feb 13, 2023 | |
| Title | Dose Delivered to the Wrong Treatment Site |
| Event Description | The following information was provided by the Texas Department of State Health Services (the Agency) via email:
On February 13, 2023, the Agency was notified that a patient was prescribed to receive 35.74 mCi (1.32 GBq) of Y-90 microspheres to the right lobe of the liver. The dose was given to the left lobe (wrong lobe) of a patient during treatment on February 13, 2023. The dose delivered (36.48 mCi (1.35 GBq)) to the left lobe was within 20 percent of the prescribed dose. The dose that was delivered to the left lobe is also within 20 percent of the dose that would have been prescribed for the left lobe in 2 weeks according to the physician. The treatment was clinically insignificant to the patient as both lobes were to be treated with a pending remapping of the second lobe to confirm the dosage but both have similar tumor volumes. More information will be provided as it is obtained in accordance with SA-300. NMED National Number: TX230005 Texas Incident Number: 9889 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 | |
|---|---|
| The University Of Texas Health Center At San Antonio San Antonio, Texas (NRC Region 4) | |
| License number: | L 01279 |
| Organization: | Texas Dept Of State Health Services |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+34.1 h1.421 days <br />0.203 weeks <br />0.0467 months <br />) | |
| Opened: | Chris Moore 16:06 Feb 14, 2023 |
| NRC Officer: | Karen Cotton-Gross |
| Last Updated: | Feb 15, 2023 |
| 56353 - NRC Website | |
The University Of Texas Health Center At San Antonio with Agreement State | |
WEEKMONTHYEARENS 563532023-02-13T06:00:00013 February 2023 06:00:00
[Table view]Agreement State Dose Delivered to the Wrong Treatment Site 2023-02-13T06:00:00 | |