ENS 48326

v t e ENS Event
04:00 Sep 11, 2012
Title	Agreement State Report - Patient Received Underdose of Y-90 Microspheres
Event Description	The following information was provided by the State of Tennessee via facsimile: On September 11, 2012, the Division of Radiological Health received a report from the University of Tennessee Medical Center regarding a misadministration that occurred September 11, 2012. A patient was prescribed a dose of 20.0 mCi of Y-90 SirSphere microspheres, and only 15.32 mCi was administered. The administered dosage was 23% less than prescribed and will result in an absorbed dose of 40.1 Gy less than the calculated 171.3 Gy. The reason why this event occurred is not known. The residual activity was detectable in the SirSpheres waste container which contained the V-vial; tubing, catheters, and protective radioactive waste cloths. The administered dosage is still considered to be within therapeutic range, but less than that prescribed by the physician. The patient and the referring physician were both notified on September 11, 2012. Inspectors from the Knoxville Field Office will follow-up on this incident. 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 48326 +/-
Where
University Of Tennessee Medical Center Knoxville, Tennessee (NRC Region 1)
License number:	R-47011
Organization:	Tennessee Div Of Rad Health
Reporting

Agreement State
Time - Person (Reporting Time:+228.63 h9.526 days <br />1.361 weeks <br />0.313 months <br />)
Opened:	Jerry Bingaman 16:38 Sep 20, 2012
NRC Officer:	John Knoke
Last Updated:	Sep 20, 2012
48326 - NRC Website
v • d • e

v t e Emergency Notification System
University Of Tennessee Medical Center with Agreement State
WEEKMONTHYEAR2012-09-11T04:00:00 [Table view]
[ENS list for University Of Tennessee Medical Center]

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