ENS 57845
ENS Event | |
|---|---|
04:00 Jul 7, 2025 | |
| Title | Medical Event |
| Event Description | The following report was provided by the Georgia Radioactive Materials Program via email:
The licensee called and stated that during a post treatment review with the physician conducted today, it was identified that a patient receiving yttrium-90 therapy on July 7, 2025, was underexposed due to a kink in the catheter. The prescribed dose was 0.439 GBq (11.853 mCi), but the administered dose was determined to be 0.177 GBq (4.779 mCi). This represents a 40.32 percent deviation from the prescribed dose, which exceeds the 20 percent reporting threshold. Upon further review of the patient's treatment history, it was additionally discovered that two prior underdosing events occurred on August 20, 2024, and September 30, 2024. Both events were also attributed to catheter kinking and involved dose delivery to small treatment volumes in limited target areas. [The licensee] stated that a formal written report detailing all three underdosing events, along with supporting documentation, will be submitted via email on Monday, August 4, 2025.
The following is a summary of information provided by the Georgia Radioactive Materials Program via email: The licensee provided three updated official incident reports, including two prior underdosing events that occurred on August 20, 2024, and September 30, 2024. The July 7, 2025, incomplete Y-90 dose delivery was attributed to clumping of the microspheres within the microcatheter. As part of corrective actions, the specific type of microcatheter involved in this incident has been discontinued for use in Y-90 procedures. During the administration of Y-90 microspheres on August 20, 2024, the prescribed dose was 0.224 GBq (6.0 mCi) and the administered dose was 0.150 GBq (4.1 mCi). During the Y-90 treatment performed on September 30, 2024, the prescribed dose was 0.290 GBq (7.83 mCi) and the administered dose was 0.166 GBq (4.5 mCi). Both the August 20, 2024, and September 30, 2024, underdosing events were attributed to anatomical limitations. Specifically, a small treatment volume and narrow treatment vessels, which restricted adequate flow of microspheres. As part of the corrective actions taken, it was determined that more than 30 psi of pressure is required to deliver microspheres into small vessels. Therefore, future cases involving small treatment vessels will consider the use of delivery systems capable of generating higher pressure to ensure effective dose administration. Notified R1DO (Henrion) and NMSS Events Notification (email) Georgia Incident Number: 105 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 | |
|---|---|
| Doctors Hospital Augusta, Georgia (NRC Region 1) | |
| License number: | GA 615-1 |
| Organization: | Georgia Radioactive Material Pgm |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+612.48 h25.52 days <br />3.646 weeks <br />0.839 months <br />) | |
| Opened: | Anastasia Bennett 16:29 Aug 1, 2025 |
| NRC Officer: | Jon Lilliendahl |
| Last Updated: | Aug 8, 2025 |
| 57845 - NRC Website | |
Doctors Hospital with Agreement State | |
WEEKMONTHYEARENS 578452025-07-07T04:00:0007 July 2025 04:00:00
[Table view]Agreement State Medical Event 2025-07-07T04:00:00 | |