ENS 43630

v t e ENS Event
15:20 Sep 10, 2007
Title	Medical Event - Patient Received an Underdose of Yttrium-90
Event Description	On Monday 9/10/07, the licensee was administering a 66 millicurie dose of Yttrium-90 microspheres to a patient for the treatment of liver cancer through a catheter. The patient only received a dose of 47 millicuries, a 27% underdose. The licensee is investigating the cause of the misadministration, but they believe the catheter used for the administration of the isotope failed or is leaking. The licensee believes there is no permanent functional damage to the patient. The physicians have been informed by the RSO that they need to notify the patient of the underdose and report that notification to the RSO. The treatment device is from MDS Nordion and a MDS Nordion company representative was on site during the administration of the isotope. The licensee intends to use the MDS Nordion representative for technical assistance in troubleshooting this problem once background radiation levels permit a closer inspection of the catheter. 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. * * UPDATE PROVIDED BY CINDY FLANNERY (FSME) TO JASON KOZAL ON 9/13/07 AT 1352 * * * This event (EN43630) has been reviewed and determined to be a reportable medical event.

ENS 43630 +/-
Where
Indiana University Medical Center Indianapolis, Indiana (NRC Region 3)
License number:	13-02752-03
Organization:	Indiana University Medical Center
Reporting

10 CFR 35.3045(a)(1)
Time - Person (Reporting Time:+24.72 h1.03 days <br />0.147 weeks <br />0.0339 months <br />)
Opened:	Mac Richard 16:03 Sep 11, 2007
NRC Officer:	Joe O'Hara
Last Updated:	Sep 13, 2007
43630 - NRC Website
v • d • e

v t e Emergency Notification System
Indiana University Medical Center with 10 CFR 35.3045(a)(1)
WEEKMONTHYEAR2015-04-14T14:00:00 [Table view]
[ENS list for Indiana University Medical Center]

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