ENS 51520

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v t e ENS Event
07:00 Nov 5, 2015
Title	Agreement State Report - Underdose to Patient
Event Description	The following report was received from the State of Utah via email: On 11/5/15, a 66 year-old male patient was scheduled to receive a TheraSphere infusion. The patient required a TheraSphere vial dose of 1.94 GBq Y-90 (order was for 5.5 GBq dose calibrated on 11/1/15 to deliver 1.94 GBq on 11/5/15) to treat the left hepatic lobe of the liver to a dose of 125 Gy for hepatocellular carcinoma. It was not until the Nuclear Medicine technologist returned to the In-Patient 'hot lab' to finish her calculations and make her final measurements after the procedure that she determined that the patient received a TheraSphere vial dose of 1.502 GBq instead of the prescribed vial dose of 1.94 GBq. (22.5 percent of the dose remained in the administration system.) The Nuclear Medicine Coordinator notified the Radiation Safety Officer and the authorized user. The Authorized User notified the patient. Also, the manufacturer's representative was notified. This incident is currently under investigation. Utah Event Report No.: UT150005 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. * * EVENT RETRACTION FROM GYWN CALLOWAY TO JOHN SHOEMAKER AT 1919 EST ON 1/26/16 * * * The State of Utah (Division of Waste Management) has received additional information, from the licensee, indicating that the actual underdose to the patient was < 5% and does not meet the reportability criteria. Therefore, this event is being retracted. Notified the R4DO (Farnholtz) and NMSS Events Notification via email.

ENS 51520 +/-
Where
Intermountain Medical Center Murray, Utah (NRC Region 4)
License number:	UT 1800494
Organization:	Utah Division Of Radiation Control
Reporting

Agreement State
Time - Person (Reporting Time:+37.4 h1.558 days <br />0.223 weeks <br />0.0512 months <br />)
Opened:	Mike Givens 20:24 Nov 6, 2015
NRC Officer:	John Shoemaker
Last Updated:	Jan 26, 2016
51520 - NRC Website
v • d • e

v t e Emergency Notification System
Intermountain Medical Center with Agreement State
WEEKMONTHYEAR2023-01-31T21:45:00 [Table view]
[ENS list for Intermountain Medical Center]

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