ENS Event | |
|---|---|
17:30 Aug 22, 2024 | |
| Title | Dose Administered to Wrong Segment of Liver |
| Event Description | The following information was received via email from the Virginia Radiation Materials Program (VRMP):
At approximately 1500 EDT on 8/22/2024, the VRMP was notified by the radiation safety officer (RSO) for Virginia Commonwealth University of a medical event involving a Y-90 TheraSpheres liver treatment. The event occurred on 8/22/24, at 1330 EDT. The written directive prescribed 215 Gy to segment 'A' of the liver and 142 Gy to segment 'B'. During the treatment, the Y-90 dose was administered to the wrong segment of the left hepatic lobe, segment 'A' received dose intended for segment 'B'. The prescribed dose for segment 'A' was 215 Gy (2.072 GBq) and that segment received 114Gy (1.369 GBq), which is less by 47 percent. This was realized immediately, and the procedure was ended without administering the other dose. The authorized user immediately notified the RSO who then notified the VRMP. Per the RSO, the referring physician has been notified and the patient's treatment will continue once appropriate dose calculation can be done. VRMP will follow up with an investigation. 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 | |
|---|---|
| Virginia Commonwealth University Richmond, Virginia (NRC Region 1) | |
| License number: | 760-215-1 |
| Organization: | Virginia Rad Materials Program |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+22 h0.917 days <br />0.131 weeks <br />0.0301 months <br />) | |
| Opened: | Karen Shelton 15:30 Aug 23, 2024 |
| NRC Officer: | Brian P. Smith |
| Last Updated: | Aug 23, 2024 |
| 57286 - NRC Website | |
Virginia Commonwealth University with Agreement State | |
WEEKMONTHYEARENS 572862024-08-22T17:30:00022 August 2024 17:30:00
[Table view]Agreement State Dose Administered to Wrong Segment of Liver 2024-08-22T17:30:00 | |