ENS Event | |
|---|---|
15:45 Aug 11, 2004 | |
| Title | Kentucky Agreement State Notification |
| Event Description | University of Louisville Hospital physicians were injecting a prescribed treatment of Yttrium-90 (Therasphere) 3.32 GBq (GigaBecquerel) into a patient's liver and only 0.72 Gbq was actually administered (22%). The licensee is investigating the cause of the misadministration. Initial investigation points to a tubing extension modification made to carry the dose to the targeted organ since the majority of the flow remained in the tubing. Hospital physicians have used the equipment 5 to 6 times without any incident. The licensee will send the tubing back to the manufacturer for further investigation. The physician notified the patient. |
| Where | |
|---|---|
| University Of Louisville (Hospital) Louisville, Kentucky (NRC Region 1) | |
| License number: | 202-029-22 |
| Organization: | Kentucky Dept Of Radiation Control |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+43.3 h1.804 days <br />0.258 weeks <br />0.0593 months <br />) | |
| Opened: | Matt Mckinley 11:03 Aug 13, 2004 |
| NRC Officer: | Arlon Costa |
| Last Updated: | Aug 13, 2004 |
| 40947 - NRC Website | |
University Of Louisville (Hospital) with Agreement State | |
WEEKMONTHYEARENS 409472004-08-11T15:45:00011 August 2004 15:45:00
[Table view]Agreement State Kentucky Agreement State Notification 2004-08-11T15:45:00 | |