|AGREEMENT STATE REPORT - MEDICAL MIS-ADMINISTRATION
The following report was received from the Georgia radioactive materials program environmental protection division via email:
"Augusta University Medical Center had an incident yesterday (December 5, 2019) in the Interventional Radiology (IR) Suite during a Y-90 TheraSphere procedure.
"The Y-90 TheraSphere delivery was performed in the usual fashion, per TheraSphere protocol, with 3 flushes of the administration vial. Both delivery and nuclear medicine pre-procedure preparation was performed per standard radiopharmaceutical (TheraSphere) protocol. During administration, the remaining undelivered dose became stuck/trapped in the transport vial and could not be administered.
"About 40 percent of the prescribed radiation dose was delivered to the patient, which is less than the criteria in Rule 391-3-17-.05.(115)a.1(i), which states, 'The total dose delivered differs from the prescribed dose by 20 percent or more.'
"A small amount of the Y-90 microspheres spilled onto the administration table, which was covered with absorbent towels. Augusta University staff isolated the contamination, scanned all IR Suite staff to ensure the contamination was not spread outside the immediate area, and called for assistance with clean-up. All contamination was located and cleaned-up, and all swipes have been counted and the results show no residual contamination in the suite or on any equipment in the suite. All radioactive material has been collected and is being stored and managed as radioactive waste.
"A formal written notification to your office will be submitted within 15 days of the event. This formal written notification will include all of the information required by Rule 391-3-17-.05.(115)."
Georgia Incident No.: 22
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.