ENS 50814

v t e ENS Event
05:00 Feb 10, 2015
Title	Agreement State Report - Medical Event Involving the Administration of Y-90 Microspheres
Event Description	The following information was obtained from the Commonwealth of Pennsylvania via facsimile: Notifications: The Department [Pennsylvania Department of Environmental Protection] was notified of this event on Wednesday, February 11, 2015. It is immediately reportable as per 10 CFR 35.3045(a)(1)(i). Event Description: A patient was receiving Y-90 Sirtex Sirspheres when the administering device failed and a portion of the dose was lost in the apparatus. The patient received 10.4 mCi, or 58% of the prescribed 17.82 mCi dose. Cause of the event: The device came apart during the procedure and the remainder of the dose was contained in the packaging. Actions: The Department plans a reactive inspection. Pennsylvania Event Report ID No: PA150004 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 50814 +/-
Where
Allegheny General Hospital Pittsburgh, Pennsylvania (NRC Region 1)
License number:	PA-0031
Organization:	Pa Bureau Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+53.63 h2.235 days <br />0.319 weeks <br />0.0735 months <br />)
Opened:	Joe Melnic 10:38 Feb 12, 2015
NRC Officer:	Howie Crouch
Last Updated:	Feb 12, 2015
50814 - NRC Website
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