ENS 40947

v t e ENS Event
15:45 Aug 11, 2004
Title	Kentucky Agreement State Notification
Event Description	University of Louisville Hospital physicians were injecting a prescribed treatment of Yttrium-90 (Therasphere) 3.32 GBq (GigaBecquerel) into a patient's liver and only 0.72 Gbq was actually administered (22%). The licensee is investigating the cause of the misadministration. Initial investigation points to a tubing extension modification made to carry the dose to the targeted organ since the majority of the flow remained in the tubing. Hospital physicians have used the equipment 5 to 6 times without any incident. The licensee will send the tubing back to the manufacturer for further investigation. The physician notified the patient.

ENS 40947 +/-
Where
University Of Louisville (Hospital) Louisville, Kentucky (NRC Region 1)
License number:	202-029-22
Organization:	Kentucky Dept Of Radiation Control
Reporting

Agreement State
Time - Person (Reporting Time:+43.3 h1.804 days <br />0.258 weeks <br />0.0593 months <br />)
Opened:	Matt Mckinley 11:03 Aug 13, 2004
NRC Officer:	Arlon Costa
Last Updated:	Aug 13, 2004
40947 - NRC Website
v • d • e

v t e Emergency Notification System
University Of Louisville (Hospital) with Agreement State
WEEKMONTHYEAR2004-08-11T15:45:00 [Table view]
[ENS list for University Of Louisville (Hospital)]

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