ENS Event | |
|---|---|
17:00 Sep 21, 2023 | |
| Title | Medical Underdose |
| Event Description | The following information was provided by the Oregon Department of Health Radiation Protection via email:
At 1000 PDT on September 21, 2023, during an administration of a split-dose of Y-90 [yttrium] SirSpheres to the liver, the first dose was not completely delivered to the patient. The second dose, same lobe but a different site, was delivered completely. (First prescribed dose: 7.2mCi; First delivered dose: 5.614 mCi) The physician does not believe additional treatment will be needed but the case will be discussed by the licensee in a follow-up conference. The senior radiologist believes there was a `clump of spheres' remaining at the hub of the syringe for the first dose, resulting in under-dosing the patient by more than 20 percent. Corrective action is still to be determined. Oregon Event Report Number: 23-0051 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 | |
|---|---|
| Oregon Health &Amp; Sciences University Portland, Oregon (NRC Region 4) | |
| License number: | ORE-90013 |
| Organization: | Or Dept Of Health Rad Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+287.7 h11.988 days <br />1.712 weeks <br />0.394 months <br />) | |
| Opened: | Michelle Martin 16:42 Oct 3, 2023 |
| NRC Officer: | Karen Cotton-Gross |
| Last Updated: | Oct 5, 2023 |
| 56775 - NRC Website | |
with Agreement State | |
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