ENS 52851

v t e ENS Event
17:00 Jul 12, 2017
Title	Agreement State Report - Misadministration of Treatment
Event Description	The following information was received from the State of Colorado via email: This is an initial report regarding a misadministration event in Colorado. University of Colorado Hospital (License Number: CO 828-01) had a misadministration of Y-90 microspheres (SIRTex SIRSpheres) on Wednesday, July 12, 2017. At approximately 11 [MDT], the post administration measurements of the waste from the SIRSpheres Administration indicated that the activity administered to segment 2/3 of the patient's liver was only 68.7 percent of the prescribed activity. The written directive called for an activity of 0.24 GBq and residual waste activity measurements indicated that 0.165 GBq was delivered. The physician indicated that stasis was not reached during the administration to this segment. There was a separate administration to segment [four] of the liver in which stasis was reached. Follow-up information will be provided after they are available. 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 52851 +/-
Where
University Of Colorado Hospital Aurora, Colorado (NRC Region 4)
License number:	CO 828-01
Organization:	Colorado Dept Of Health
Reporting

Agreement State
Time - Person (Reporting Time:+17.55 h0.731 days <br />0.104 weeks <br />0.024 months <br />)
Opened:	Shiya Wang 10:33 Jul 13, 2017
NRC Officer:	Vince Klco
Last Updated:	Jul 13, 2017
52851 - NRC Website
v • d • e

v t e Emergency Notification System
University Of Colorado Hospital with Agreement State
WEEKMONTHYEAR2023-05-24T19:00:00 [Table view]
[ENS list for University Of Colorado Hospital]

Navigation menu