ENS Event | |
|---|---|
05:00 Jul 18, 2017 | |
| Title | Kansas Agreement State Report - Medical Event |
| Event Description | The following information was received from the state of Kansas via email:
A medical event occurred during a Yttrium-90 TheraSphere treatment of a patient's liver cancer. The patient received approximately 24 percent of the dose prescribed in the written directive. There was no harm to the patient other than the inconvenience of rescheduling the treatment to receive the remainder of the dose. [The licensee is] investigating the event and will submit a report within the required 15 days. With this procedure the vial containing the TheraSpheres cannot be viewed due to being inside a lead pig. Therefore, a digital radiation dosimeter is placed near the delivery device. As the dose is delivered to the patient, the readings drop to or near zero. In this case, the technologists and the physician stated the dosimeter was reading 0.0 at the end of the procedure. [The licensee's] immediate corrective action will be for radiation safety staff to verify the instrument readings when the physician feels the entire dose has been delivered. The prescribed dose or quantity was not provided by the State. 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 | |
|---|---|
| University Of Kansas Hospital Authority Kansas City, Kansas (NRC Region 4) | |
| License number: | 18-C801 |
| Organization: | Kansas Dept Of Health & Environment |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+36.18 h1.508 days <br />0.215 weeks <br />0.0496 months <br />) | |
| Opened: | James Uhlemeyer 17:11 Jul 19, 2017 |
| NRC Officer: | Howie Crouch |
| Last Updated: | Jul 19, 2017 |
| 52864 - NRC Website | |
University Of Kansas Hospital Authority with Agreement State | |
WEEKMONTHYEARENS 544272019-12-06T19:28:0006 December 2019 19:28:00
[Table view]Agreement State Agreement State Report - Dose Delivered Differed by More than 20 Percent ENS 528642017-07-18T05:00:00018 July 2017 05:00:00 Agreement State Kansas Agreement State Report - Medical Event 2019-12-06T19:28:00 | |