ENS Event | |
|---|---|
14:30 Jul 14, 2015 | |
| Title | Agreement State Report - Dose To Improper Treatment Site |
| Event Description | The following information was received by the State of Ohio via email:
On July 14, 2015, the licensee reported that the intended delivery of Y-90 SirSpheres went to the small bowel instead of the right lobe of the liver during a procedure that morning. The intervention physician felt that the dose delivery was not going where it should be going and discontinued the treatment. Scanning the patient identified that the Y-90 microspheres were delivered to the small bowel. The original prescribed dose to the right lobe of the liver was 78 Gy with 20.5 mCi. The delivered dose of 36 Gy with 7.79 mCi went to the small bowel instead of the liver right lobe. The patient was notified at the time of the event. The interventional physician was the referring physician and AU [Authorized User]. Ohio Report: OH150007 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 Hospitals Of Cleveland Cleveland, Ohio (NRC Region 3) | |
| License number: | Oh-0211018007 |
| Organization: | Ohio Bureau Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+20.33 h0.847 days <br />0.121 weeks <br />0.0278 months <br />) | |
| Opened: | Karl Van Ahn 10:50 Jul 15, 2015 |
| NRC Officer: | Vince Klco |
| Last Updated: | Jul 15, 2015 |
| 51233 - NRC Website | |
University Hospitals Of Cleveland with Agreement State | |
WEEKMONTHYEARENS 551522019-06-12T04:00:00012 June 2019 04:00:00
[Table view]Agreement State Failure to Report Underdose to Patient ENS 512332015-07-14T14:30:00014 July 2015 14:30:00 Agreement State Agreement State Report - Dose to Improper Treatment Site ENS 449732008-12-15T04:00:00015 December 2008 04:00:00 Agreement State Incident Involving Co-60 Gamma Knife During Patient Treatment 2019-06-12T04:00:00 | |