ENS 46718
ENS Event | |
|---|---|
05:00 Mar 16, 2011 | |
| Title | Agreement State Report - Yttrium-90 Microspsheres Administered Dose Less Than Prescribed Dose |
| Event Description | The following was received from the State of Arkansas via email:
On March 16, 2011, a patient was scheduled for two administrations of Y-90 microspheres. The first dose administration was conducted without incident. As the second dose was being delivered, the syringe plunger was accidentally rotated so that the stopper inside the syringe was engaged momentarily causing a pause in administration. Due to the pause, the microspheres in the catheter at the time of the pause settled in the catheter and were not administered to the patient. The facility has contacted the manufacturer of the administration device. On the morning of March 17, 2011, Interventional Radiology informed the referring physician, and patient of the event. Conditions requiring reporting of this event: The dose differs from the prescribed dose by more than 50 Rem to an organ The delivered dose of 69.56 Gy was 24.44 Gy (2444 rads) less than the optimal dose of 94 Gy and 10.44 Gy (1044 rads) less than the minimal dose in the prescription range. And the total dose delivered differs from the prescribed dose by twenty percent (20%) or more. The total dose delivered, 69.56 Gy, differed by twenty-six percent (26%) from the optimal dose of 94 Gy and was outside the treatment prescription range of 80-150 Gy. Arkansas Event Number: 03-11-03 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.
Corrective actions concerning the TheraSphere medical event were submitted to the Arkansas Department of Health. The University of Arkansas for Medical Sciences (UAMS) now requires that all Interventional Radiology staff and residents who will participate in the injection of Y-90 TheraSpheres will receive training on the injection technique prior to administering the radioisotope. The staff will practice the injection process by using normal saline. The staff has also been instructed to administer the dose in a continuous manner without pause. Lastly, the catheter tubing was previously being flushed three times, as recommended by the manufacturer, but the tubing will now be flushed at least five times. The Arkansas Department of Health considers this incident to be closed. Notified R4DO (Proulx) and FSME EO (McIntosh). |
| Where | |
|---|---|
| University Of Arkansas For Medical Sciences Little Rock, Arkansas (NRC Region 4) | |
| License number: | Ark-001-02110 |
| Organization: | Arkansas Department Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+395.05 h16.46 days <br />2.351 weeks <br />0.541 months <br />) | |
| Opened: | Steve Mack 16:03 Apr 1, 2011 |
| NRC Officer: | Dong Park |
| Last Updated: | May 6, 2011 |
| 46718 - NRC Website | |
University Of Arkansas For Medical Sciences with Agreement State | |
WEEKMONTHYEARENS 571782024-06-07T05:00:0007 June 2024 05:00:00
[Table view]Agreement State Y-90 Microsphere Underdose ENS 538792019-02-13T13:24:00013 February 2019 13:24:00 Agreement State En Revision Imported Date 6/5/2019 ENS 511302015-06-04T05:00:0004 June 2015 05:00:00 Agreement State Agreement State Report - Medical Treatment Incorrect Dose ENS 467182011-03-16T05:00:00016 March 2011 05:00:00 Agreement State Agreement State Report - Yttrium-90 Microspsheres Administered Dose Less than Prescribed Dose 2024-06-07T05:00:00 | |