ENS 49881

v t e ENS Event
05:00 Mar 5, 2014
Title	Agreement State Report - Under Dose Involving Yttrium 90 Microspheres
Event Description	The following information was received by email: On March 6, 2014, UMass Memorial Health Care (license number 60-0096) reported [to the Massachusetts Radiation Control Program] that on March 5, 2014 they had under dosed a patient by more than 20% using Y-90 microspheres. Further pertinent data is: Prescribed Activity: 26.4 mCi of Y-90 (in one fraction injection) Delivered Activity: 20.4 mCi of Y-90 (more than 20% different from prescribed) Resulting in: Prescribed Liver dose: = 32.6 Gy Delivered Liver dose: = 25.2 Gy Dose difference in organ: = 740 rads (i.e., greater than 50 rem and 20% difference) Note Also: Effective dose (requested): 32.6 Gy * 0.04 = 1.3 Sv Effective dose (delivered): 25.2 Gy * 0.04 = 1.0 Sv Effective dose difference: 1.3-1.0=0.3 Sv = 30 rem (greater than 5 rem difference) 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 49881 +/-
Where
Umass Memorial Health Care Worcester, Massachusetts (NRC Region 1)
License number:	60-0096
Organization:	Ma Radiation Control Program
Reporting

Agreement State
Time - Person (Reporting Time:+51.45 h2.144 days <br />0.306 weeks <br />0.0705 months <br />)
Opened:	Michael Whalen 08:27 Mar 7, 2014
NRC Officer:	Dong Park
Last Updated:	Mar 7, 2014
49881 - NRC Website
v • d • e

v t e Emergency Notification System
Umass Memorial Health Care with Agreement State
WEEKMONTHYEAR2019-04-02T14:42:00 [Table view]
[ENS list for Umass Memorial Health Care]

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