ENS 52457
ENS Event | |
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05:00 Dec 20, 2016 | |
Title | Agreement State Report - Medical Underdose |
Event Description | The following report was received via fax:
On December 20, 2016, a leak occurred during an administration of Yttrium-90 (Y-90) TheraSpheres to a patient, resulting in less than 80% of the prescribed dosage being administered. A total of about 8.99 millicurie of Y-90 activity was administered; or 34.6% of the prescribed 25.95 mCi activity. The prescribed dose was 17,470 rad (174.7 gray), with the leak resulting in a dose to the patient's liver of about 6,040 rad (60.4 Gy). The leak also caused contamination of the administration area, which was immediately and successfully decontaminated. As an under-dose, no immediate harmful effect to the patient resulted from the event. The referring physician and patient were made aware of the event during the procedure. Pennsylvania event: PA-160040 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 | |
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University Of Pennsylvania Philadelphia, Pennsylvania (NRC Region 1) | |
License number: | PA-0131 |
Organization: | Pa Bureau Of Radiation Protection |
Reporting | |
Agreement State | |
Time - Person (Reporting Time:+55.77 h2.324 days <br />0.332 weeks <br />0.0764 months <br />) | |
Opened: | David Allard 12:46 Dec 22, 2016 |
NRC Officer: | Mark Abramovitz |
Last Updated: | Dec 22, 2016 |
52457 - NRC Website
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University of Pennsylvania with Agreement State | |
WEEKMONTHYEARENS 573752024-10-09T04:00:0009 October 2024 04:00:00
[Table view]Agreement State Patient Underdose ENS 570812024-04-17T04:00:00017 April 2024 04:00:00 Agreement State Medical Underdose ENS 566612023-08-05T15:07:0005 August 2023 15:07:00 Agreement State Medical Underdose ENS 570862023-01-31T04:00:00031 January 2023 04:00:00 Agreement State Medical Event ENS 570852022-12-29T04:00:00029 December 2022 04:00:00 Agreement State Medical Event ENS 570842022-12-28T04:00:00028 December 2022 04:00:00 Agreement State Medical Event ENS 558892022-05-04T04:00:0004 May 2022 04:00:00 Agreement State Underdose ENS 558512022-04-18T04:00:00018 April 2022 04:00:00 Agreement State Patient Underdose ENS 553372021-07-02T04:00:0002 July 2021 04:00:00 Agreement State Patient Under Dose ENS 549642020-10-20T04:00:00020 October 2020 04:00:00 Agreement State Missing Licensed Material ENS 534302018-05-25T04:00:00025 May 2018 04:00:00 Agreement State En Revision Imported Date 10/15/2018 ENS 525042017-01-19T05:00:00019 January 2017 05:00:00 Agreement State Agreement State Report - Received Dose Less than Prescribed Dose ENS 524572016-12-20T05:00:00020 December 2016 05:00:00 Agreement State Agreement State Report - Medical Underdose ENS 483032012-09-11T04:00:00011 September 2012 04:00:00 Agreement State Agreement State Report - Patient Underexposure Using Yttrium-90 Sir-Spheres Treatment ENS 482292012-08-23T04:00:00023 August 2012 04:00:00 Agreement State Agreement State Report - Patient Underexposure Using Yttrium-90 Sir-Spheres Treatment ENS 481372012-07-26T04:00:00026 July 2012 04:00:00 Agreement State Agreement State Report - Medical Event Involving an Underdose with Yttrium-90 Spheres ENS 477632012-03-20T04:00:00020 March 2012 04:00:00 Agreement State Agreement State Report - Underdose During Liver Disease Treatment ENS 474352011-11-10T12:00:00010 November 2011 12:00:00 Agreement State Agreement State Report - Underdosage of Theraspheres ENS 461012010-07-07T04:00:0007 July 2010 04:00:00 Agreement State Agreement State Report - Delivered Dose Differed from the Prescribed Dose by Greater than 50% ENS 457272010-01-21T05:00:00021 January 2010 05:00:00 Agreement State Agreement State Report - Brachytherapy Implants Outside of the Intended Treatment Area 2024-04-17T04:00:00 | |