ENS 48098

v t e ENS Event
21:00 Jul 10, 2012
Title	Agreement State Report - Underdose During a Yttrium-90 Therasphere Treatment
Event Description	The following information was provided by the Ohio Bureau of Radiation Protection via e-mail: A written directive was given for a patient to receive 115 mCi of Y-90 TheraSpheres microspheres. During the delivery of the microspheres, stasis occurred before the full quantity of the written directive delivered. The licensee did not expect to reach stasis, and will be sending the delivery system to the manufacturer after the remaining Y-90 decays to verify that there was not an equipment malfunction. The licensee calculates that the patient received 68.6 mCi, which is only 60% of the written directive (a 40% underdose). The written directive did not indicate include the phrase 'or until stasis'. The licensee has notified the attending physician. The licensee will be contacting the patient's physician prior to contacting the patient. The licensee states that there are no adverse effects to the patient. No corrective action is planned at this time. Event Discovered: July 11, 2012 at 11:00 am Event Date: July 10, 2012 at 5:00 pm Reporting criteria - medical event OAC 3701:1-58-101(a)(1)(a) 10 CFR 35.3045(a)(1)(i) Ohio Event Report #2012-017 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 48098 +/-
Where
Universities Hospital Of Cleveland Cleveland, Ohio (NRC Region 3)
License number:	02110180007
Organization:	Ohio Bureau Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+40.17 h1.674 days <br />0.239 weeks <br />0.055 months <br />)
Opened:	Karl Von Ahn 13:10 Jul 12, 2012
NRC Officer:	Bill Huffman
Last Updated:	Jul 12, 2012
48098 - NRC Website
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v t e Emergency Notification System
Universities Hospital Of Cleveland with Agreement State
WEEKMONTHYEAR2012-07-10T21:00:00 [Table view]
[ENS list for Universities Hospital Of Cleveland]

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