"The licensee has conducted three inventories of all sources, reviewed all shipping logs, and have searched (both visually and with a survey meter) areas, floors, and drawers where devices are built and stored. (NDC) discovered a 25 mCi Americium-241 (Am-241) source was missing from their inventory. "ODH received a notification last night, that NDC Technologies, Inc. The following information was provided by the Ohio Department of Health (ODH) via email: It does not necessarily result in harm to the patient. There were no immediate adverse health effects, and the IR would monitor the patient for the next two weeks (about five half-lives)."Ī Medical Event may indicate potential problems in a medical facility's use of radioactive materials. The IR discussed everything with the patient before the patient had left the recovery area. This indicated a very small amount of the dose was delivered. "Further viewing of the images of the upper abdomen of the patient by the Interventional Radiologist (IR) demonstrated a very faint outline of the right lobe of the liver (the intended treatment area). The license was researching a way to calculate the amount of activity that may have been in these additional materials. The radiation survey reading of these materials was 140 mR/hr. "The licensee also noted increased radiation activity in other materials used in the procedure. The licensee contacted the manufacturer the same day regarding the event. At this time, the licensee was questioning if any of the dose was administered. Initial imaging of the patient directly following the procedure did not show activity around the target area and surface radiation readings of the patient in this area was 0.06 mR/hr. After measuring these materials, it appeared the patient received 41.7 Gy to the target site (liver). During the line check while attempting to administer the microspheres, the licensee experienced some difficulties, stopped the procedure, and noticed a higher-than-normal radiation reading of the delivery system and associated materials. The event involved a patient scheduled to receive a prescribed therapy dose of 120 Gy of yttrium-90 Theraspheres microspheres. "The ND DEQ received a call from Innovis Health, LLC, Fargo, North Dakota, (ND License No. The following information was provided by the North Dakota (ND) Department of Environmental Quality (DEQ) via telephone and email: AGREEMENT STATE REPORT - PATIENT UNDERDOSE
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