ENS 51039

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v t e ENS Event
05:00 May 1, 2015
Title	Agreement State Report - Patient Received Less than Prescribed Y-90 Dose
Event Description	The following was received from the State of Wisconsin via email: On May 4, 2015, the Wisconsin Radiation Protection Section received a notice from an Authorized Medical Physicist [AMP] at Gundersen Lutheran Medical Center, Inc., of a medical event that occurred during a Yttrium-90 Therasphere procedure on May 1, 2015. The licensee did not have enough information to determine if the procedure constituted a medical event on May 1, 2015. Upon further evaluation, the AMP determined it was a medical event as of 3 pm CST May 4, 2015. The patient was scheduled to receive two separate Y-90 Therasphere doses to two separate segments of the liver. During the first injection, the overpressure valve opened and filled the overflow vial with the Authorized User applying very little pressure to the saline filled syringe. The patient was to get 147 Gy to Segment 6 of the liver. From residue measurements, the patient received 35.5 percent or 52.2 Gy to Segment 6. The Radiation Protection Section will perform an investigation and update through NMED [Nuclear Material Events Database]. Event Report ID No.: WI150006 * * UPDATE AT 0938 EDT ON 5/18/2015 FROM CAL WALTON TO MARK ABRAMOVITZ * * * The correct Wisconsin event ID is WI150007. Notified the R3DO (Peterson) and NMSS (via e-mail). 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 51039 +/-
Where
Gundersen Lutheran Medical Center, Inc. La Crosse, Wisconsin (NRC Region 3)
License number:	063-1121-01
Organization:	Wisconsin Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+84.87 h3.536 days <br />0.505 weeks <br />0.116 months <br />)
Opened:	Emily Eggers 17:52 May 4, 2015
NRC Officer:	Dong Park
Last Updated:	May 18, 2015
51039 - NRC Website
v • d • e

v t e Emergency Notification System
Gundersen Lutheran Medical Center, Inc. with Agreement State
WEEKMONTHYEAR2015-05-01T05:00:00 [Table view]
[ENS list for Gundersen Lutheran Medical Center, Inc.]

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ENS Notification