ENS Event | |
|---|---|
15:20 Sep 10, 2007 | |
| Title | Medical Event - Patient Received An Underdose Of Yttrium-90 |
| Event Description | On Monday 9/10/07, the licensee was administering a 66 millicurie dose of Yttrium-90 microspheres to a patient for the treatment of liver cancer through a catheter. The patient only received a dose of 47 millicuries, a 27% underdose. The licensee is investigating the cause of the misadministration, but they believe the catheter used for the administration of the isotope failed or is leaking. The licensee believes there is no permanent functional damage to the patient. The physicians have been informed by the RSO that they need to notify the patient of the underdose and report that notification to the RSO. The treatment device is from MDS Nordion and a MDS Nordion company representative was on site during the administration of the isotope. The licensee intends to use the MDS Nordion representative for technical assistance in troubleshooting this problem once background radiation levels permit a closer inspection of the catheter.
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 | |
|---|---|
| Indiana University Medical Center Indianapolis, Indiana (NRC Region 3) | |
| License number: | 13-02752-03 |
| Organization: | Indiana University Medical Center |
| Reporting | |
| 10 CFR 35.3045(a)(1) | |
| Time - Person (Reporting Time:+24.72 h1.03 days <br />0.147 weeks <br />0.0339 months <br />) | |
| Opened: | Mac Richard 16:03 Sep 11, 2007 |
| NRC Officer: | Joe O'Hara |
| Last Updated: | Sep 13, 2007 |
| 43630 - NRC Website | |
Indiana University Medical Center with 10 CFR 35.3045(a)(1) | |
WEEKMONTHYEARENS 509832015-04-14T14:00:00014 April 2015 14:00:00
[Table view]10 CFR 35.3045(a)(1) Y-90 Microsphere Dose Less than Prescribed ENS 495422013-11-14T18:50:00014 November 2013 18:50:00 10 CFR 35.3045(a)(1) Y-90 Microshpere Dose Less than Prescribed ENS 477222011-07-05T05:00:0005 July 2011 05:00:00 10 CFR 35.3045(a)(1) Medical Event - Dosage Delivered to Patient Differed by 20% from Prescribed Dosage ENS 450342009-04-29T17:30:00029 April 2009 17:30:00 10 CFR 35.3045(a)(1) Medical Event Involving an Underdosage During Treatment for Liver Cancer ENS 436302007-09-10T15:20:00010 September 2007 15:20:00 10 CFR 35.3045(a)(1) Medical Event - Patient Received an Underdose of Yttrium-90 ENS 424532006-03-29T21:30:00029 March 2006 21:30:00 10 CFR 35.3045(a)(1) Different Length Bucket and Applicator Used During Brachytherapy Dose ENS 424692005-01-17T18:00:00017 January 2005 18:00:00 10 CFR 35.3045(a)(1) Medical Event Involving Delivered Dose Less than the Prescribed Dose 2015-04-14T14:00:00 | |