ENS 41576

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v t e 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.

ENS 41576 +/-
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
v • d • e

v t e Emergency Notification System
University Of Wisconsin - Madison with Agreement State
WEEKMONTHYEAR2025-09-11T18:06:00 [Table view]
[ENS list for University Of Wisconsin - Madison]

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ENS Notification