ENS 48699

v t e ENS Event
21:00 Jan 16, 2013
Title	Agreement State Report - Dose Different from Prescribed Using Yttrium-90 Therasphere Treatment
Event Description	The following event report was received from the State of Utah Division of Radiation Control via facsimile: The Utah Division of Radiation Control was notified at 11:45 a.m. MST on Thursday, January 17, 2013 of a medical event associated with a radioembolization brachytherapy treatment of liver cancer. Notification was provided by the licensee's Radiation Safety Officer. This incident report is the initial notification to the NRC Operations Center. The licensee's radiation safety officer reported to the Division that the treatment plan prescribed 1.33 GBq of yttrium-90 for treatment of liver cancer. The patient received 0.798 GBq of yttrium associated with the TheraSphere product. After the administration of the dosage, a nuclear medicine technologist determined that the total prescribed dosage was not delivered to the patient, as radioactive material was found to remain in the dosage vial and the administration apparatus. The licensee is working with the manufacturer of the treatment delivery system to determine the cause of the medical event. Utah Event Report ID : UT130001 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 48699 +/-
Where
Intermountain Medical Center Murray, Utah (NRC Region 4)
License number:	UT 1800494
Organization:	Utah Division Of Radiation Control
Reporting

Agreement State
Time - Person (Reporting Time:+206.02 h8.584 days <br />1.226 weeks <br />0.282 months <br />)
Opened:	Craig Jones 11:01 Jan 25, 2013
NRC Officer:	Bill Huffman
Last Updated:	Jan 25, 2013
48699 - NRC Website
v • d • e

v t e Emergency Notification System
Intermountain Medical Center with Agreement State
WEEKMONTHYEAR2023-01-31T21:45:00 [Table view]
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