ENS 47727

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v t e ENS Event
05:00 Mar 8, 2012
Title	Agreement State Report - Underdose During Hepatic Treatment Using Yttrium-90 Theraspheres
Event Description	The following information was received via e-mail from the State of North Carolina Radiation Protection Section: The agency [NC Radiation Protection Section] was notified of a medical event at UNC - Chapel Hill by the RSO. The event occurred yesterday. The patient was administered a Y-90 therasphere dose. Three flushes were done and proper surveys were made to ensure none of the dose was left in the IV lines. As per protocol, dose delivered is calculated via measurement of the administration vial and the waste collection vial. At this point it was noted that the patient only received 78% of the prescribed dose. The surveys indicate that the dose was left in the administration vial. Exact prescription dose was not provided at this time. No cause has been determined yet. There was no spilling, but the physician did note that it was harder to push the plunger for the flush to go through than he usually experiences. A second dose was delivered to a different patient using the same lot today, and the administration was successful (95% delivered). The patient who received the underdose has not yet been notified due to other health complications not caused by the underdosage. The patient's physician is aware and waiting for an appropriate opportunity to inform the patient. It has been determined that a second dose will not be administered since the physician has deemed the dose received adequate. 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.

ENS 47727 +/-
Where
University Of North Carolina At Chapel Hill Chapel Hill, North Carolina (NRC Region 1)
Organization:	Nc Div Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+34.95 h1.456 days <br />0.208 weeks <br />0.0479 months <br />)
Opened:	Diana Sulas 15:57 Mar 9, 2012
NRC Officer:	Bill Huffman
Last Updated:	Mar 9, 2012
47727 - NRC Website
v • d • e

v t e Emergency Notification System
University Of North Carolina At Chapel Hill with Agreement State
WEEKMONTHYEAR2012-03-08T05:00:00 [Table view]
[ENS list for University Of North Carolina At Chapel Hill]

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