ENS 50908

v t e ENS Event
05:00 Mar 18, 2015
Title	Agreement State Report - Under Dosage of Patient Undergoing Treatment
Event Description	The following report was received from the State of Wisconsin Department of Health Services via email: On March 18, 2015, the Wisconsin Radiation Protection Section received a notice from the Radiation Safety Officer (RSO) at Wheaton Franciscan Healthcare-Franklin of a medical event that occurred from a halted administration of Yttrium 90 SIR-Spheres. During the administration, air bubbles were noticed to be collecting in the tubing delivering the dose. The procedure was stopped in order to avoid injecting air bubbles into the patient. The prescribed dose was 33.26 mCi. 26.35 mCi had been delivered to the patient, based on pre-and post-procedure assays of the material. This is 79.2% of the prescribed dose. The licensee believes placement of the needles drawing the solution was to blame for the collection of air bubbles. The Radiation Protection Section will perform an investigation and update through NMED. Wisconsin Event Report ID No.: WI150005 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 50908 +/-
Where
Wheaton Franciscan Healthcare - Franklin, Inc. Franklin, Wisconsin (NRC Region 3)
License number:	079-1375-01
Organization:	Wisconsin Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+36.3 h1.513 days <br />0.216 weeks <br />0.0497 months <br />)
Opened:	Kyle Walton 17:18 Mar 19, 2015
NRC Officer:	Jeff Herrera
Last Updated:	Mar 19, 2015
50908 - NRC Website
v • d • e

v t e Emergency Notification System
Wheaton Franciscan Healthcare - Franklin, Inc. with Agreement State
WEEKMONTHYEAR2015-03-18T05:00:00 [Table view]
[ENS list for Wheaton Franciscan Healthcare - Franklin, Inc.]

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