ENS 46665
ENS Event | |
|---|---|
15:00 Mar 9, 2011 | |
| Title | Medical Event Involving Administration Of Greater Than Ordered Dose |
| Event Description | An Authorized User physician from the University of Michigan Department of Radiation Oncology planned two liver infusion treatments for a patient with unresectable hepatocellular carcinoma using Y-90 Theraspheres. As part of treatment preparation, an MRI was performed on the patient to determine the patient's liver segment volumes. Liver segment volumes are used in calculating the Y-90 activity needed to deliver the prescribed radiation dose to particular segments of the liver. The first treatment was to the right lobe and medial segment of the patient's liver and was performed on 12/15/2010. It proceeded without incident and in accordance with the written directive.
The Authorized User physician scheduled a second separate treatment to the patient's left lobe to be performed on 3/9/2011. The Authorized User ordered a 74.4 Gy dose to the left lobe of the liver. The medical physicist calculated a corresponding dosage of 60.5 mCi of Y-90 to be infused into the left lobe of the liver. However, in arriving at the Y-90 activity needed, a medical physicist used the liver segment volumes for the right lobe and medial segment combined instead of that for the left lobe. The volume of the right lobe and medial segment is much larger than that for the left lobe. As a result, the Y-90 dosage of 60.5 mCi exceeded what was actually needed to deliver the prescribed dose of 74.4 Gy. The Y-90 was infused into to the left lobe on 3/9/2011 at approximately 10 [EST]. Based on the Authorized User's reassessment of the left lobe volume, the dose to the left lobe is calculated, post-administration, to be 159.4 Gy. The patient was notified of the event on 3/9/2011. The referring physician was also notified on the morning of 3/10/2011. The Authorized User physician has concluded that the elevated radiation dose to the patient's liver will not result in permanent medical damage or loss of function. Upon initial investigation this event appears to possibly be due to a problem in transcription however causes and corrective actions are still being evaluated. 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 Michigan Hospital Ann Arbor, Michigan (NRC Region 3) | |
| License number: | 21-00215-04 |
| Organization: | University Of Michigan Hospital |
| Reporting | |
| 10 CFR 35.3045(a)(1) | |
| Time - Person (Reporting Time:+20.25 h0.844 days <br />0.121 weeks <br />0.0277 months <br />) | |
| Opened: | Mark Driscoll 11:15 Mar 10, 2011 |
| NRC Officer: | John Shoemaker |
| Last Updated: | Mar 10, 2011 |
| 46665 - NRC Website | |
University Of Michigan Hospital with 10 CFR 35.3045(a)(1) | |
WEEKMONTHYEARENS 536952018-10-25T04:00:00025 October 2018 04:00:00
[Table view]10 CFR 35.3045(a)(1) Medical Event - Underdose ENS 479462012-05-17T12:00:00017 May 2012 12:00:00 10 CFR 35.3045(a)(1) Medical Event - Patient Injected with Wrong Radiopharmaceutical and Quantity ENS 466652011-03-09T15:00:0009 March 2011 15:00:00 10 CFR 35.3045(a)(1) Medical Event Involving Administration of Greater than Ordered Dose ENS 454362009-10-14T21:00:00014 October 2009 21:00:00 10 CFR 35.3045(a)(1) Patient Received Approximately 76% of the Prescribed Dose 2018-10-25T04:00:00 | |