ENS 44033

v t e ENS Event
07:00 Mar 5, 2008
Title	Agreement State Report - Misadministration of Y-90 Microspheres
Event Description	The State provided the following information via facsimile: A medical licensee notified the Department of a misadministration during a Y-90 microsphere procedure, The problem was identified at the conclusion of the procedure when staff noted that 50% of the Y-90 microspheres were still in the application kit, resulting in a 50% underdose to the patient. The licensee's medical physicist, who is investigating the incident, was unsure if the problem was caused by a faulty injection valve or human error (e.g.. The valve was turned to the wrong position during the procedure). The licensee is Skyridge Medical Center Denver, CO, License 1053-01. No other details are available at this time. The Department has initiated an investigation of this incident. * * UPDATE ON 03/08/2008 AT 0847 EST FROM FSME (FLANNERY) TO ALEXANDER * * * The NRC has reviewed this event and determined it to be a reportable medical event. 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.

ENS 44033 +/-
Where
Skyridge Medical Center Denver, Colorado (NRC Region 4)
License number:	1053-01
Organization:	Colorado Dept Of Health
Reporting

Agreement State
Time - Person (Reporting Time:+9.23 h0.385 days <br />0.0549 weeks <br />0.0126 months <br />)
Opened:	Ed Stroud 16:14 Mar 5, 2008
NRC Officer:	Joe O'Hara
Last Updated:	Mar 7, 2008
44033 - NRC Website
v • d • e

v t e Emergency Notification System
Skyridge Medical Center with Agreement State
WEEKMONTHYEAR2008-03-05T07:00:00 [Table view]
[ENS list for Skyridge Medical Center]

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