ENS 50433

v t e ENS Event
04:00 Sep 4, 2014
Title	Agreement State Report - Medical Event Due to Misadministration of Y-90 Theraspheres
Event Description	The following information was received via email: A Y-90 TheraSphere liver therapy procedure resulted in delivered doses to the liver and lungs that differed from the prescribed dose. The revised Lung Shunt Fraction (LSF) value was used to recalculate the actual radiation dose to lungs and LT liver lobe. The results are that the lungs received 34.5 Gy (instead of 3.7 Gy) and the LT liver lobe received 67 Gy (instead of 117 Gy). Also, it is calculated that the LT liver lobe was implanted with a Y-90 activity dose of 0.82 GBq (22.2 mCi) while the lungs received a Y-90 activity dose of 0.69 GBq (18.64 mCi) since the patient was implanted with 1.50 GBq (40.53 mCi) of Y-90. The patient's family was notified. UVA staff are meeting to analyze the root cause of the event. RMP [Virginia Radioactive Materials Program] staff will review UVA's findings and determine what further actions are necessary. Virginia Event Report ID No.: VA-2014-16 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 50433 +/-
Where
University of Virginia Charlottesville, Virginia (NRC Region 1)
License number:	540-248-1
Organization:	Virginia Rad Materials Program
Reporting

Agreement State
Time - Person (Reporting Time:+108.62 h4.526 days <br />0.647 weeks <br />0.149 months <br />)
Opened:	Mike Welling 16:37 Sep 8, 2014
NRC Officer:	Donald Norwood
Last Updated:	Sep 8, 2014
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