The following information was provided by the
Oregon Department of Health Radiation Protection (the Department) via email:
During a Y-90 Therasphere microsphere therapy treatment of the entire left lobe of the liver, the catheter was positioned incorrectly inside the hepatic artery, resulting in sections 2 and 3 of the left lobe being treated instead of sections 1 and 4. Prescribed dose was 100 Gy to the entire left lobe. The licensee discovered the event on 6/14/2024 and notified the Department on 6/14/2024 at 1226 PDT.
The patient has not been notified yet, but the provider is meeting with the patient to do so this week and discuss. The licensee is unsure whether the referring physician has been notified at this time but is going to find out. There will likely be an effect on patient outcome and plan of care. The licensee is also determining the actual doses given to sections 2/3 and 1/4 but information provided indicates 96 mCi of the dose was given to sections 2/3. The Department is awaiting further information from the licensee."
Oregon Event Report ID Number: OR-24-0030
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.