ENS 50372

v t e ENS Event
04:00 Aug 14, 2014
Title	Agreement State Report - Medical Underdose to Liver
Event Description	The following was received from the State of Ohio via email: The licensee prepared and delivered a therapeutic dose of TheraSpheres to a patient's liver on August 14, 2014. The written directive was for 120 Gy to the liver with 27 mCi of Y-90 TheraSpheres. On August 15, 2014, the licensee discovered that 20% of the dose that was supposed to be administered to the patient was still in the bottom of the vial. Although the licensee prepared the vial in accordance with the manufacturer's instructions, 20% of the TheraSpheres remained in the bottom of the vial and did not go into suspension. The patient and referring physician have been notified. The Bureau [Ohio Bureau of Radiation Protection] will be conducting a follow-up investigation regarding this event. The patient received 96 Gy to the liver instead of the prescribed 120 Gy. Ohio incident # OH140010 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 50372 +/-
Where
Ohio State University Medical Center Columbus, Ohio (NRC Region 3)
License number:	02110250037
Organization:	Ohio Bureau Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+34.88 h1.453 days <br />0.208 weeks <br />0.0478 months <br />)
Opened:	Karl Von Ahn 14:53 Aug 15, 2014
NRC Officer:	Daniel Mills
Last Updated:	Aug 15, 2014
50372 - NRC Website
v • d • e

v t e Emergency Notification System
Ohio State University Medical Center with Agreement State
WEEKMONTHYEAR2014-08-14T04:00:00 [Table view]
[ENS list for Ohio State University Medical Center]

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