ENS 53996
ENS Event | |
|---|---|
04:00 Apr 3, 2019 | |
| Title | |
| Event Description | The following is a synopsis of the information received from the Radioactive Materials Program of Georgia received via email:
On April 3, 2019, an underdose of Y-90 TheraSpheres was administered to a patient. Only 65% of the prescribed dose was administered. On April 5, 2019, the remainder of the prescribed dose was delivered to the patient. There is no definitive cause identified at this time but the licensee has concluded that it was probably a delivery equipment problem (perhaps with the tubing). The licensee will follow-up with a formal report.
The state of Georgia amended the original report to state that the deliver apparatus is awaiting decay to background and will be examined locally or will be sent to the manufacturer for a root cause analysis. The prescribed dose was 127 Gy. The delivered dose was 59.8 Gy which is 47% of prescribed dose. As stated above, the patient was informed and returned two days later to complete the treatment. NMED Item: 190182 Notified R1DO (Schroeder) and NMSS Events Notification (email).
The state of Georgia has amended the original report and the update from 4/29/20 as follows: -the prescribed dose was 122 Gy -the delivered dose was 78.8 Gy -the difference is 64.5 percent. This same event was also reported under NRC Event Notification #54010 which has been deleted from the report database. Notified R1DO (Schroeder) and NMSS Events Notification (email). 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 | |
|---|---|
| Georgia Radioactive Material Pgm Atlanta, Georgia (NRC Region 1) | |
| License number: | GA 292-1 |
| Organization: | Georgia Radioactive Material Pgm |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+225.35 h9.39 days <br />1.341 weeks <br />0.309 months <br />) | |
| Opened: | Irene Bennett 13:21 Apr 12, 2019 |
| NRC Officer: | Caty Nolan |
| Last Updated: | Apr 30, 2020 |
| 53996 - NRC Website | |
Georgia Radioactive Material Program with Agreement State | ||||
WEEKMONTHYEARENS 560652022-08-23T16:00:00023 August 2022 16:00:00 Agreement State Lost Radioactive Portable Gauge ENS 548822020-09-02T04:00:0002 September 2020 04:00:00 Agreement State | Agreement State Report - Medical Event - Underdose ENS 548792020-08-27T04:00:00027 August 2020 04:00:00 Agreement State | Agreement State Report - Loss of Medical Seed After Removal from Patient ENS 548172020-07-21T04:00:00021 July 2020 04:00:00 Agreement State | ENS 546942020-05-04T04:00:0004 May 2020 04:00:00 Agreement State Agreement State Report - Patient Underdose ENS 546622020-03-31T04:00:00031 March 2020 04:00:00 Agreement State Agreement State Report - Loss of Iodine-125 Seed ENS 541102019-06-11T04:00:00011 June 2019 04:00:00 Agreement State Agreement State Report - Patient Under Dosage Due to Air Being Trapped in the Delivery Line ENS 545492019-05-02T05:00:0002 May 2019 05:00:00 Agreement State Agreement State Report - Broken Density Gauge Shutter ENS 539962019-04-03T04:00:0003 April 2019 04:00:00 Agreement State Agreement State Report - Underdose Administration of Y-90 Theraspheres ENS 545502019-01-18T05:00:00018 January 2019 05:00:00 Agreement State Agreement State Report - Improper Disposal of I-125 Seed ENS 545412018-12-18T05:00:00018 December 2018 05:00:00 Agreement State Agreement State Report - Leaking Promethium-147 Source ENS 545652018-06-29T05:00:00029 June 2018 05:00:00 Agreement State Agreement State Report - Lost Iodine-125 Seed ENS 545372018-04-03T05:00:0003 April 2018 05:00:00 Agreement State Agreement State Report - Stuck Open Shutter ENS 545632017-11-06T05:00:0006 November 2017 05:00:00 Agreement State Agreement State Report - Leaking Cesium-137 Source ENS 546442017-06-09T04:00:0009 June 2017 04:00:00 Agreement State Agreement State Report - Stuck Shutter ENS 545642016-08-09T05:00:0009 August 2016 05:00:00 Agreement State Agreement State Report - Lost I-125 Source 2022-08-23T16:00:00 [Table view] | |