ENS 47135

v t e ENS Event
05:00 Aug 7, 2011
Title	Agreement State Report - Therasphere Treatment to Wrong Lobe of Liver
Event Description	The following was received via fax: The Wisconsin Department of Health Services (DHS) received a phone call from the Radiation Safety Officer (RSO) on August 8, 2011 that a patient received a dose of 1.05 GBq of Y-90 Theraspheres on July 7, 2011 to the wrong side of the liver as documented on the written directive. The patient was scheduled for treatment of 1.04 GBq Y-90 Theraspheres for multinodular hepatocellular cancer (HCC) to the left lobe of the liver. The dosimetry for Y-90 Theraspheres was based on volume (mass) of the lobe bearing the tumors (the patient has tumors on both lobes, right and left). A treatment plan was created for the left lobe (using the volume of the left lobe) but during the procedure the right lobe was treated with the prescribed dose for the left lobe. DHS will be conducting an investigation on August 12, 2011 and the licensee will be submitting a 15 day written report concerning the medical event. WI Event Number: 110012 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 47135 +/-
Where
Uw-Madison Madison, Wisconsin (NRC Region 3)
License number:	025-1323-01
Organization:	Wisconsin Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+55.43 h2.31 days <br />0.33 weeks <br />0.0759 months <br />)
Opened:	Chris Timmerman 12:26 Aug 9, 2011
NRC Officer:	Charles Teal
Last Updated:	Aug 9, 2011
47135 - NRC Website
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v t e Emergency Notification System
Uw-Madison with Agreement State
WEEKMONTHYEAR2011-08-07T05:00:00 [Table view]
[ENS list for Uw-Madison]

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