ENS Event | |
|---|---|
05:00 Nov 25, 2025 | |
| Title | Medical Event |
| Event Description | The following information was provided by the Ohio Bureau of Radiation Protection via email:
A patient was scheduled to receive 30 mCi Y-90 to the right lobe of the liver in segments 5/6, but only 11.2 mCi was delivered. This is an underdose of 63 percent. The authorized user (AU) and interventional radiologist physician verified catheter placement by contrast injection and fluoroscopy prior to the procedure and continued to monitor the catheter position during the treatment. During the procedure, the AU noted that saline was leaking from the top of the acrylic vial holder inside the delivery box and that there was insufficient pressure to mix/suspend the microspheres in the dose vial. It was also noted the catheter had moved from the original target. The AU determined the dose could not be delivered as prescribed and abandoned the procedure. The patient and referring physician were notified. Investigation is pending. Ohio item number: OH250004 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 | |
|---|---|
| Aultman Hospital Canton, Ohio (NRC Region 3) | |
| License number: | 02120770003 |
| Organization: | Ohio Bureau Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+34.37 h1.432 days <br />0.205 weeks <br />0.0471 months <br />) | |
| Opened: | Michael Rubadue 15:22 Nov 26, 2025 |
| NRC Officer: | Robert A. Thompson |
| Last Updated: | Nov 26, 2025 |
| 58064 - NRC Website | |
Aultman Hospital with Agreement State | |
WEEKMONTHYEARENS 580642025-11-25T05:00:00025 November 2025 05:00:00
[Table view]Agreement State Medical Event 2025-11-25T05:00:00 | |