ENS 51287

v t e ENS Event
17:00 Jul 30, 2015
Title	Medical Event Resulting from Actual Treatment Dose 30 Percent Greater than Prescribed
Event Description	On 7/31/2015, a patient was undergoing a single treatment for liver cancer using Y-90 microspheres (SIR-Spheres) with a prescribed dose from the physicians written directive of 29.43 milliCi. On 8/4/2015, it was discovered that the patient actually received 38.2 milliCi dose due a calculation error based on the physician's initial written directive when the physician had decided on a final dose reduction prior to treatment. The physician has been notified and believes that there will be no adverse effects to the patient. The patient will be notified on 8/5/2015. 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 51287 +/-
Where
Sanford Health Sioux Falls, South Dakota (NRC Region 4)
License number:	40-12378-01
Organization:	Sanford Health
Reporting

10 CFR 35.3045(a)(1)
Time - Person (Reporting Time:+121.15 h5.048 days <br />0.721 weeks <br />0.166 months <br />)
Opened:	Steven Moeckly 18:09 Aug 4, 2015
NRC Officer:	Jeff Rotton
Last Updated:	Aug 4, 2015
51287 - NRC Website
v • d • e

v t e Emergency Notification System
Sanford Health with 10 CFR 35.3045(a)(1)
WEEKMONTHYEAR2015-07-30T17:00:00 [Table view]
[ENS list for Sanford Health]

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