ENS 52697

v t e ENS Event
04:00 Apr 12, 2017
Title	Agreement State Report - Less Than Intended Dose Administered To The Patient
Event Description	The following information was provided by the State of New York via facsimile: On 04/12/2017, a patient with widespread neoplasm of liver, intrahepatic bile duct, received treatment with Y90 SIRTEX microspheres to 2 separate segments in the right lobe. The intended activities were 0.946 GBq (25.6 mCi) to a small segment and 2.38 GBq (64.3 mCi) to the large segment. On 4/18/17, during a review of the patient's medical record, the AU [authorized user] physician discovered that the activity ordered for the large lesion was 0.38 GBq, not 2.38 GBq, as the written directive had stated. NYS DOH [New York State Department of Health] was informed on 4/19/17. Both the patient and the referring physician have been informed. AU physician stated that there is no harm to the patient, because they plan to administer the deficit dose to this segment in the right lobe during the procedure scheduled to treat the left lobe next month. The licensee stated that documentation/communication appears to be the primary cause. Facility is investigating. Will update when more information becomes available. NY Event Report ID No. NYDOH-NY-17-07 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.

ENS 52697 +/-
Where
Not Provided Not Provided, New York (NRC Region 1)
Organization:	New York State Dept. Of Health
Reporting

Agreement State
Time - Person (Reporting Time:+203.63 h8.485 days <br />1.212 weeks <br />0.279 months <br />)
Opened:	Janaki Krishnamoorthy 15:38 Apr 20, 2017
NRC Officer:	Dong Park
Last Updated:	Apr 20, 2017
52697 - NRC Website
v • d • e

v t e Emergency Notification System
Not Provided with Agreement State
WEEKMONTHYEAR2020-11-23T04:00:00 [Table view]
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