ENS 45602

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v t e ENS Event
05:00 Dec 30, 2009
Title	Underdose to Patient
Event Description	The Richard L. Roudebush VA Medical Center holds VHA Permit Number 13-00694-03 under the VA's Master Material License (NRC License Number 03-23853-01VA). For a patient treatment on December 30, 2009, involving Yttrium-90 microspheres, the medical center discovered (on same date) that the total activity delivered to the treatment site was less than 80% of the total activity documented in the written directive. The medical event was discovered when a waste container, which contained used catheters, lines, gloves, tongs, tape, etc., from the treatment were assayed. The waste materials indicated a higher than expected residual activity equal to about 25 percent of the activity that was in the source vial prior to treatment. Examination of the waste materials revealed that nearly all of the residual activity was distributed somewhat uniformly along the length of the approximately 100 cm microcatheter tubing. The current estimate is that about 47.03 millicuries were delivered to the patient, and 15.67 millicuries were in the wastes. The prescribed activity was 63.2 millicuries. Therefore, the patient was under-dosed by about 25.6%. Because this deviation exceeds 20%, a medical event is considered to have occurred per 10 CFR 35.3045(a)(1). Although a lower-than-intended activity was administered, the permittee estimates that the absorbed dose to the target organ was around 109 gray and was within the therapeutic target range of 100 to 150 gray. Therefore, no adverse biological effects to the patient are expected. 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.test

ENS 45602 +/-
Where
Richard L. Roudebush Va Medical Center Indianapolis, Indiana (NRC Region 3)
License number:	03-23853-01VA
Organization:	Department Of Veterans Affairs
Reporting

10 CFR 35.3045(a)(1)
Time - Person (Reporting Time:+31.3 h1.304 days <br />0.186 weeks <br />0.0429 months <br />)
Opened:	Thomas Huston 12:18 Dec 31, 2009
NRC Officer:	Pete Snyder
Last Updated:	Dec 31, 2009
45602 - NRC Website
v • d • e

v t e Emergency Notification System
Richard L. Roudebush Va Medical Center with 10 CFR 35.3045(a)(1)
WEEKMONTHYEAR2009-12-30T05:00:00 [Table view]
[ENS list for Richard L. Roudebush Va Medical Center]

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