ENS Event | |
|---|---|
14:45 Apr 27, 2011 | |
| Title | Patient Received Less than Prescribed Dose Due to an Occlusion in the Delivery Catheter |
| Event Description | A patient received 14.8 Gray rather than the 63 Gray prescribed treatment to the upper portion of the liver using SIRSpheres manufactured by Sirtex. Only 0.7 GBq of the 3 GBq Y-90 microspheres were delivered to the treatment site due to an occlusion in the micro catheter. The treating physician terminated the dose administration after encountering difficulty in "pushing" the syringe contents through the micro catheter. While removing the catheter a small release of microspheres occurred due to the trapped pressure. The spill was contained and immediately cleaned up.
The Hospital contacted the manufacturer and will return the dose unit for analysis. Both the patient and the referring physician have been informed. There was no adverse impact to the patient who has been rescheduled for a compensatory dose next week. 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 | |
|---|---|
| Beaumont Hospitals Royal Oak, Michigan (NRC Region 3) | |
| License number: | 21-01333-01 |
| Organization: | Beaumont Hospitals |
| Reporting | |
| 10 CFR 35.3045(a)(1) | |
| Time - Person (Reporting Time:+1.33 h0.0554 days <br />0.00792 weeks <br />0.00182 months <br />) | |
| Opened: | Sheryl Schultz 16:05 Apr 27, 2011 |
| NRC Officer: | Steve Sandin |
| Last Updated: | Apr 27, 2011 |
| 46791 - NRC Website | |
Beaumont Hospitals with 10 CFR 35.3045(a)(1) | |
WEEKMONTHYEARENS 467912011-04-27T14:45:00027 April 2011 14:45:00
[Table view]10 CFR 35.3045(a)(1) Patient Received Less than Prescribed Dose Due to an Occlusion in the Delivery Catheter 2011-04-27T14:45:00 | |