ENS Event | |
|---|---|
04:00 Aug 14, 2014 | |
| Title | Agreement State Report - Medical Underdose to Liver |
| Event Description | The following was received from the State of Ohio via email:
The licensee prepared and delivered a therapeutic dose of TheraSpheres to a patient's liver on August 14, 2014. The written directive was for 120 Gy to the liver with 27 mCi of Y-90 TheraSpheres. On August 15, 2014, the licensee discovered that 20% of the dose that was supposed to be administered to the patient was still in the bottom of the vial. Although the licensee prepared the vial in accordance with the manufacturer's instructions, 20% of the TheraSpheres remained in the bottom of the vial and did not go into suspension. The patient and referring physician have been notified. The Bureau [Ohio Bureau of Radiation Protection] will be conducting a follow-up investigation regarding this event. The patient received 96 Gy to the liver instead of the prescribed 120 Gy. Ohio incident # OH140010 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 | |
|---|---|
| Ohio State University Medical Center Columbus, Ohio (NRC Region 3) | |
| License number: | 02110250037 |
| Organization: | Ohio Bureau Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+34.88 h1.453 days <br />0.208 weeks <br />0.0478 months <br />) | |
| Opened: | Karl Von Ahn 14:53 Aug 15, 2014 |
| NRC Officer: | Daniel Mills |
| Last Updated: | Aug 15, 2014 |
| 50372 - NRC Website | |
Ohio State University Medical Center with Agreement State | |
WEEKMONTHYEARENS 503722014-08-14T04:00:00014 August 2014 04:00:00
[Table view]Agreement State Agreement State Report - Medical Underdose to Liver 2014-08-14T04:00:00 | |