ENS 49542

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v t e ENS Event
18:50 Nov 14, 2013
Title	Y-90 Microshpere Dose Less than Prescribed
Event Description	On the afternoon of 11/14/2013, a patient was scheduled for a Y-90 microsphere radioembolization treatment at Indiana University Medical Center under NRC License 13-02752-03. The treatment consisted of two separate doses of Y-90 for which two separate written directives were prepared. Segment 4 of the patient's liver was prescribed a dosage of 27.0 mCi, and the right lobe of the liver was prescribed a dosage of 88.0 mCi. At 13:50 on 11/14/2013, following measurement of the remaining activity after injection of the Y-90 microspheres, it was determined that a dose of 19.5 mCi was delivered to segment 4 (72.2% of the intended dose). Shortly thereafter, at 14:06, a dose of 87.5 mCi of Y-90 was delivered to the right lobe (99.4% of the intended dose). Both procedures appeared to proceed in accordance with standard operating procedures, and no abnormalities were identified during the procedure by the Interventional Radiology Physician or the Health Physicist supporting the procedure. Following the procedure, personnel and area surveys were performed using an SE International GM meter and no contamination of personnel, the room or equipment was identified. The container holding residual activity from the segment 4 treatment has been set aside for decay and further analysis. As the activity delivered to segment 4 of the liver meets the criteria in 10 CFR 35.3045(a)(1) and 10 CFR 35.3045(a)(1)(i), a report to the NRC Operations Center shall be made in accordance with 10 CFR 35.3045(c). The attending physician and patient will be contacted in accordance with 10 CFR 35.3045(e). 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 49542 +/-
Where
Indiana University Medical Center Indianapolis, Indiana (NRC Region 3)
License number:	13-02752-03
Organization:	Indiana University Medical Center
Reporting

10 CFR 35.3045(a)(1)
Time - Person (Reporting Time:+18.62 h0.776 days <br />0.111 weeks <br />0.0255 months <br />)
Opened:	Mack Richards 13:27 Nov 15, 2013
NRC Officer:	Bill Huffman
Last Updated:	Nov 15, 2013
49542 - NRC Website
v • d • e

v t e Emergency Notification System
Indiana University Medical Center with 10 CFR 35.3045(a)(1)
WEEKMONTHYEAR2015-04-14T14:00:00 [Table view]
[ENS list for Indiana University Medical Center]

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