ENS Event | |
|---|---|
15:30 Jun 19, 2023 | |
| Title | Patient Underdose |
| Event Description | The following information was provided by the Arkansas Department of Health via email:
On June 19, 2023, at approximately 1300 CDT, the licensee contacted the Arkansas Department of Health to report a medical event from Jefferson Regional Medical Center, Pine Bluff, Arkansas. The Radiation Safety Officer, Imaging Services Compliance Specialist, called to report a mishap with their first procedures with Y-90. It appears that their patient was to have received 19.8 Gray. However, due to equipment or patient issues the patient received only 6% (i.e. 2.6 Gray). The original injection was to have been 68.5 mCi. The report from the licensee is as follows: This is a termination of the Y-90 therapy due to stasis of the administration. 'Based on dosimeter readings of the Y-90 vial, and Geiger-Mueller meter measurements of the equipment, the microspheres were blocked in a tubing connector and did not fully reach the patient and/or organ. There was no spillage or contamination of microspheres from the Y-90 dose. The tubing and catheter were placed in appropriate shielding for long term decay in storage. Below and attached are the calculations we received from the lead Nuclear Medicine technologist and Therasphere representative.' Written Directive: 68.6 mCi Administration: 64.9 mCi at 1030 [CDT] Start: 1138 [CDT] Stasis Termination: 1209 [CDT] Dose to patient: 3.6 mCi AR event number: ARK-2023-004 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 | |
|---|---|
| Jefferson Regional Medical Center Pine Bluff, Arkansas (NRC Region 4) | |
| License number: | ARK-0623-02120 |
| Organization: | Arkansas Department Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+19.18 h0.799 days <br />0.114 weeks <br />0.0263 months <br />) | |
| Opened: | Susan Elliott 10:41 Jun 20, 2023 |
| NRC Officer: | Ernest West |
| Last Updated: | Jun 20, 2023 |
| 56582 - NRC Website | |
Jefferson Regional Medical Center with Agreement State | |
WEEKMONTHYEARENS 565822023-06-19T15:30:00019 June 2023 15:30:00
[Table view]Agreement State Patient Underdose 2023-06-19T15:30:00 | |