ENS 51470

v t e ENS Event
20:30 Oct 14, 2015
Title	Colorado Agreement State Report - Patient Received 40 Percent Less than Prescribed Dose
Event Description	The following information was provided by the State of Colorado via email: The [licensee] RSO reported that a patient received 40 percent less than the prescribed dose during a TheraSphere (Y-90) treatment on 10/14/2015. The exact cause is still under investigation. Initial written direction was for 120 Gy. However, due to unavailability of this dose the written directive was amended to 140 Gy and the dose was ordered. The AU [Authorized User] reported that stasis was not reached and it was believed the patient received the entire dose. The associated survey meter was reading 0 and the AU flushed the system 3 times - the meter continued to read 0. The procedure ended around 1430 MDT. After the procedure the AMP [Authorized Medical Physicist] reviewed the paperwork, took waste measurements and performed calculations. At this point 40 Gy was found in the waste. The RSO was notified at 1545 MDT. At this time, it is not known if the patient has been notified. 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 51470 +/-
Where
University Of Colorado Hospital Aurora, Colorado (NRC Region 4)
License number:	CO828-01
Organization:	Colorado Dept Of Health
Reporting

Agreement State
Time - Person (Reporting Time:+17.42 h0.726 days <br />0.104 weeks <br />0.0239 months <br />)
Opened:	Carrie Romanchek 13:55 Oct 15, 2015
NRC Officer:	Jeff Rotton
Last Updated:	Oct 15, 2015
51470 - NRC Website
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v t e Emergency Notification System
University Of Colorado Hospital with Agreement State
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