ENS 52176

v t e ENS Event
14:00 Aug 11, 2016
Title	Agreement State Report - Underadministration of Y-90 Microspheres
Event Description	The following was received from State of Maryland via email: Greater than 20 percent underadministration of the prescribed activity was administered to the left lobe of the patient's liver. Underadministration may have been up to 60 percent less than the prescribed written activity (preliminary estimate). Prescribed written directive activity to left lobe of liver was 25 mCi. Preliminary assessment of administered activity is 14 mCi. Radioactive material ended up in the patient catheter, chucks, and on the floor. All areas were cleaned and evaluated by the licensee. The licensee states that both the patient and referring doctor have been notified of the event. The licensee has history of many successful therapies of this type. The licensee is investigating the event, but has not yet determined a root cause. The licensee is sending a detailed written report to the State. 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 52176 +/-
Where
University Of Maryland, Baltimore Baltimore, Maryland (NRC Region 1)
License number:	07-014-01
Organization:	Maryland Dept Of The Environment
Reporting

Agreement State
Time - Person (Reporting Time:+24.88 h1.037 days <br />0.148 weeks <br />0.0341 months <br />)
Opened:	Ray Manley 14:53 Aug 12, 2016
NRC Officer:	Dong Park
Last Updated:	Aug 12, 2016
52176 - NRC Website
v • d • e

v t e Emergency Notification System
University Of Maryland, Baltimore with Agreement State
WEEKMONTHYEAR2016-08-11T14:00:00 [Table view]
[ENS list for University Of Maryland, Baltimore]

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