ENS 52807

v t e ENS Event
08:00 Jun 14, 2017
Title	Patient Received a Higher Dose than Prescribed
Event Description	On 6/14/17 a patient undergoing treatment using Sir-Spheres (Y-90) received a dose of 540 Gray instead of the 110 Gray prescribed. This occurred due to a calibration error. The prescribing physician discussed the error with the patient who was released and returned home. The Radiation Safety Officer (RSO) is investigating the incident. No adverse effect to the patient has been observed to date. * * UPDATE PROVIDED BY YONGLI NING TO JEFF ROTTON AT 1816 EDT ON 06/28/2017 * * * The original report is being updated to reflect that the dose information provided initially was for the liver (prescribed organ). Thera-Spheres were used in the procedure versus the Sir-Spheres as stated in the original report. The licensee also provided received dose information for the lung of 25.76 Gray from the event described above. Notified the R4DO (Kellar) and NMSS Events Notification group via email. 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 52807 +/-
Where
Providence Alaska Medical Center Anchorage, Alaska (NRC Region 4)
License number:	50-17838-01
Organization:	Providence Alaska Medical Center
Reporting

10 CFR 35.3045(a)(1)
Time - Person (Reporting Time:+31.43 h1.31 days <br />0.187 weeks <br />0.0431 months <br />)
Opened:	Yongli Ning 15:26 Jun 15, 2017
NRC Officer:	Steve Sandin
Last Updated:	Jun 28, 2017
52807 - NRC Website
v • d • e

v t e Emergency Notification System
Providence Alaska Medical Center with 10 CFR 35.3045(a)(1)
WEEKMONTHYEAR2017-06-14T08:00:00 [Table view]
[ENS list for Providence Alaska Medical Center]

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