ENS 57073
ENS Event | |
|---|---|
15:30 Apr 12, 2024 | |
| Title | Agreement State - Medical Underdose |
| Event Description | The following information was provided by the South Carolina Department of Health and Environmental Control (Department) via email:
The South Carolina Department of Health and Environmental Control was notified via telephone at approximately 1301 [EDT] on 4/12/24, that a medical event had been discovered by the licensee on 4/12/24 at approximately 1130 [EDT]. The Medical University of South Carolina (MUSC) reports an underdose to a patient's liver during a Y-90 microsphere procedure by 78 percent of the prescribed 120 Gray (Gy) dose. The licensee estimates that the patient received 27 Gy, which is 22 percent of the intended 120 Gy dose. The licensee reports that the total dose or activity delivered differs from the prescribed dose or activity, as documented in the written directive, by 20 percent or more. The patient was notified of this medical event verbally. The licensee reports no immediate or ongoing concerns to public health and safety. Department inspectors will be dispatched to the facility to investigate this event. This event is still under investigation by the South Carolina Department of Health and Environmental Control. 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.
The following update was provided by the South Carolina Department of Health and Environmental Control via email: The licensee has submitted a 15-day written report. This event is still under investigation by the South Carolina Department of Health and Environmental Control. The internal identification number for this event is SC240001. Notified R1DO (Werkheiser), NMSS_EVENTS_NOTIFICATION via email.
The following information was provided by the licensee via email: Department Inspectors performed an on-site investigation on 05/23/24. Details of the event were consistent with the licensee's notification and written report. The licensee attributes the root cause of the failure to administer the full dosage to the administration lines due to administration line blockage, specifically a faulty needle in the plunger of the administration kit. This event is considered closed. Notified R1DO (Eve), NMSS_EVENTS_NOTIFICATION via email. |
| Where | |
|---|---|
| Medical University Of South Carolina Charleston, South Carolina (NRC Region 1) | |
| License number: | 081 |
| Organization: | Sc Dept Of Health & Env Control |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+-1.62 h-0.0675 days <br />-0.00964 weeks <br />-0.00222 months <br />) | |
| Opened: | Korina Koci 13:53 Apr 12, 2024 |
| NRC Officer: | Ernest West |
| Last Updated: | Jun 14, 2024 |
| 57073 - NRC Website
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Medical University of South Carolina with Agreement State | |
WEEKMONTHYEARENS 570732024-04-12T15:30:00012 April 2024 15:30:00
[Table view]Agreement State Agreement State - Medical Underdose ENS 527032017-04-20T04:00:00020 April 2017 04:00:00 Agreement State Agreement State Report - Delivered Dose Less than Prescribed Dose ENS 423062006-01-16T05:00:00016 January 2006 05:00:00 Agreement State Agreement State Report - Medical Misadministration 2024-04-12T15:30:00 | |