ENS Event | |
|---|---|
06:00 Jan 3, 2019 | |
| Title | En Revision Imported Date 1/15/2019 |
| Event Description | EN Revision Text: MEDICAL EVENT - Y-90 THERASPHERES ADMINISTERED TO THE WRONG LIVER SEGMENT
A medical event occurred on 1/3/2019 at Washington University in St. Louis. The patient treatment plan called for 1.06 GBq of Y-90 TheraSpheres to be administered to Segments 6 and 7 of the patient's liver. However, 1.02 GBq of Y-90 TheraSpheres were administered to Segments 5 and 8 of the patient's liver instead. The patient and the referring physician were notified of the event. Washington University in St. Louis has initiated an investigation of the event.
The following was received via email from the licensee: As a follow up to the phone call placed today (1/14/19) at 12:56 pm EST, [the licensee radiation safety officer] is writing to retract the report of a event number 53814. The initial report of a suspected medical event with the administration of Y-90 microspheres to a patient was made on 1/4/19 at 12:15 pm EST. After taking the limitations of the imaging software into account, the reviewing team of clinicians have evaluated that the Y-90 microspheres were administered to the correct patient, with the correct dosage and correct route of administration, and in agreement with the Written Directive. Notified R3DO (PELKE) and NMSS vis 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 | |
|---|---|
| Washington University In St. Louis St. Louis, Missouri (NRC Region 3) | |
| License number: | 24-00167-11 |
| Organization: | Washington University In St. Louis |
| Reporting | |
| 10 CFR 35.3045(a)(3) | |
| Time - Person (Reporting Time:+30.25 h1.26 days <br />0.18 weeks <br />0.0414 months <br />) | |
| Opened: | Maxwell Amurao 12:15 Jan 4, 2019 |
| NRC Officer: | Donald Norwood |
| Last Updated: | Jan 14, 2019 |
| 53814 - NRC Website | |
Washington University In St. Louis with 10 CFR 35.3045(a)(3) | |
WEEKMONTHYEARENS 538142019-01-03T06:00:0003 January 2019 06:00:00
[Table view]10 CFR 35.3045(a)(3) En Revision Imported Date 1/15/2019 2019-01-03T06:00:00 | |