ENS Event | |
|---|---|
15:45 Apr 8, 2009 | |
| Title | Agreement State Report - Misadministration Involving Y-90 Microspheres |
| Event Description | The following was received via facsimile:
N.C. Radiation Protection Section was notified of a misadministration involving Y-90 microspheres. The licensee reports that the administered dosage was 24 percent less than the prescribed dosage. Licensee reports no equipment malfunction and no leakage of radioactive material from the delivery device. Licensee has notified patient and there are no plans to perform a second administration. Licensee is contacting vendor to assist in investigation. N.C. Radiation Protection has not received any media attention as of this report. No press release has been issued. The North Carolina Event Report ID Number for this event is NC-09-22. 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 North Carolina Hospitals Chapel Hill, North Carolina (NRC Region 1) | |
| License number: | 068-0565-1 |
| Organization: | Nc Div Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+22.05 h0.919 days <br />0.131 weeks <br />0.0302 months <br />) | |
| Opened: | Henry Barnes 13:48 Apr 9, 2009 |
| NRC Officer: | Donald Norwood |
| Last Updated: | Apr 9, 2009 |
| 44979 - NRC Website | |
University Of North Carolina Hospitals with Agreement State | |
WEEKMONTHYEARENS 449792009-04-08T15:45:0008 April 2009 15:45:00
[Table view]Agreement State Agreement State Report - Misadministration Involving Y-90 Microspheres ENS 448932009-03-05T17:00:0005 March 2009 17:00:00 Agreement State Underdose to Patient Differs >20% of Intended Dose 2009-04-08T15:45:00 | |