ENS Event | |
|---|---|
14:30 Apr 8, 2005 | |
| Title | Potential Medical Event Involving a Therapeutic Administration of Yttrium-90 |
| Event Description | The licensee provided the following information via facsimile (licensee text in quotes):
On Friday, April 8, 2005 at approximately 8:30 a.m., the Wisconsin Radiation Protection Section (RPS) received notification from the University of Wisconsin, Madison, WI (license number 25-1323-01) of a potential medical event involving a therapeutic radiation dose from a Yittrium-90 Zevelin treatment in which the delivered dose may have differed from the prescribed dose by more than 0.5 Sv (50 rem) and by 20% or more of the prescribed dose. [HFS 157.72 (1) (a) 1.] On Tuesday, April 5, 2005, a physician at the University of Wisconsin Hospital and Clinics, Madison, WI administered a 48 mCi dose of Y-90 Zevalin to a patient. Based upon patient weight and platelet count, the intended dose should have been 28 mCi. The dose was dispensed as a unit dose by a nuclear pharmacy and administered as received. There is no indication of a written directive. The error was not discovered until Thursday, April 7 during a licensee review of records. The licensee is investigating the incident. The ordering physician has been notified HFS 157.72 (1) (a) 1. requires a licensee to report an event in which the administration of radioactive material or resulting radiation results in 'A dose that differs from the prescribed dose by more than 0.05 Sv (5 rem), 0.5 Sv (50 Rem) to an organ or tissue or 0.5 Sv (50 rem) shallow dose equivalent to the skin and the total dose delivered differs from the prescribed dose by 20% or more'. DHFS, RPS staff plan to investigate. |
| Where | |
|---|---|
| University Of Wisconsin - Madison Madison, Wisconsin (NRC Region 3) | |
| License number: | 25-1323-01 |
| Organization: | Wisconsin Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+-0.38 h-0.0158 days <br />-0.00226 weeks <br />-5.20524e-4 months <br />) | |
| Opened: | Paul Schmidt 14:07 Apr 8, 2005 |
| NRC Officer: | Wesley Held |
| Last Updated: | Apr 8, 2005 |
| 41576 - NRC Website | |
University Of Wisconsin - Madison with Agreement State | |
WEEKMONTHYEARENS 579212025-09-11T18:06:00011 September 2025 18:06:00
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