ENS 47633

v t e ENS Event
07:00 Feb 2, 2012
Title	Agreement State Report - Dose Delivered to Wrong Patient
Event Description	The following report was received from the State of Utah via email: Two patients were scheduled to receive TheraSphere infusions containing microspheres of Yttrium-90 on the same day [02/02/12]. Patient #1 was to receive 5.32 GBq for a treatment dose of 120 Gy. Patient #2 was to receive 1.77 GBq for a treatment dose of 120 Gy. Patient #1 received the dosage for Patient #2 (i.e., 1.77 GBq). The error was detected prior to Patient #2 receiving a dosage. The licensee determined that Patient #1 received a dose that was 33% lower than the prescribed dose in the written directive. The licensee determined this to be a medical event. However, the licensee did not provide enough information to determine if this event is or is not an Abnormal Occurrence. An on-site investigation is planned by the Utah Division of Radiation Control to occur within the next several days. Utah Event Report ID Number: UT120001. 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 47633 +/-
Where
Intermountain Medical Center Murray, Utah (NRC Region 4)
License number:	UT1800494
Organization:	Utah Division Of Radiation Control
Reporting

Agreement State
Time - Person (Reporting Time:+28.17 h1.174 days <br />0.168 weeks <br />0.0386 months <br />)
Opened:	Phillip Griffin 11:10 Feb 3, 2012
NRC Officer:	Steve Sandin
Last Updated:	Feb 3, 2012
47633 - NRC Website
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v t e Emergency Notification System
Intermountain Medical Center with Agreement State
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