ENS 52504
ENS Event | |
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05:00 Jan 19, 2017 | |
Title | Agreement State Report - Received Dose Less than Prescribed Dose |
Event Description | The following is excerpted from an email:
On January 20, 2017 the licensee informed the Department [Pennsylvania Department of Environmental Protection Bureau of Radiation Protection] of an under dose incident involving yttrium-90 (Y-90) TheraSpheres. It is reportable as per 10 CFR 35.3045(a)(1)(i). On January 19, 2017 a patient underwent a Y-90 TheraSphere treatment. The staff reported the procedure went as planned; however, upon surveying the waste and performing a dose calculation it was found that the patient received approximately 29% of the prescribed dose. The patient was notified of this under dose on January 20, 2017. The physician utilized contrast medium to view the flow prior to the procedure and no issues were seen. No increased resistance was noted and the physician was able to flush the line post administration. The manufacturer was notified and will be conducting a joint investigation with the hospital staff. No harm is expected to the patient. A reactive inspection is planned by the Department. More information will be provided upon receipt. 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:+99.88 h4.162 days <br />0.595 weeks <br />0.137 months <br />) | |
Opened: | Joseph Melnic 08:53 Jan 23, 2017 |
NRC Officer: | Bethany Cecere |
Last Updated: | Jan 23, 2017 |
52504 - 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 | |