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
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. |
| 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 | |
Gundersen Lutheran Medical Center, Inc. with Agreement State | |
WEEKMONTHYEARENS 510392015-05-01T05:00:0001 May 2015 05:00:00
[Table view]Agreement State Agreement State Report - Patient Received Less than Prescribed Y-90 Dose 2015-05-01T05:00:00 | |