ENS 49354

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v t e ENS Event
04:00 Sep 18, 2013
Title	Agreement State Report - Underdose to Patient'S Liver
Event Description	The Commonwealth of Massachusetts submitted the following information via email: A dose that likely differs from the prescribed dose by more than 50 rem to an organ, the liver, and the total dose delivered differs from the prescribed dose by 20% or more. The licensee's radiation safety officer reported to the Agency [Massachusetts Radiation Control Program] on 9/18/2013 that on same date licensee administered yttrium-90 SIR-Spheres to patient's left lobe of liver for treatment of metastatic disease; that 16.8 millicuries of yttrium-90 was prescribed; and that 12.06 millicuries was administered resulting in an under dose of 28.1 percent. The licensee discovered the event upon measurement of waste material including dose vial as part of normal quality assurance. The licensee's radiation safety officer reported that the authorized user and the referring physician have been notified and it is unknown at time of the report whether the referring physician has elected to notify the patient. The licensee's radiation safety officer reported that medical staff does not believe that this error will adversely affect the patient treatment outcome. The licensee will submit a written report within 15 days in accordance with the [Massachusetts] requirements of 105 CMR 120.594(A)(4) to include why event occurred and actions to prevent recurrence. Root cause and corrective action are not known at this time and the Agency continues to investigate. System Name: Brachytherapy Product; Manufacturer: Sirtex Wilmington LLC 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 49354 +/-
Where
Massachusetts General Hospital Boston, Massachusetts (NRC Region 1)
License number:	60-0055
Organization:	Ma Radiation Control Program
Reporting

Agreement State
Time - Person (Reporting Time:+12.47 h0.52 days <br />0.0742 weeks <br />0.0171 months <br />)
Opened:	Joshua Daehler 16:28 Sep 18, 2013
NRC Officer:	Pete Snyder
Last Updated:	Sep 18, 2013
49354 - NRC Website
v • d • e

v t e Emergency Notification System
Massachusetts General Hospital with Agreement State
WEEKMONTHYEAR2022-08-02T19:30:00 [Table view]
[ENS list for Massachusetts General Hospital]

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ENS Notification