ENS 52864

v t e ENS Event
05:00 Jul 18, 2017
Title	Kansas Agreement State Report - Medical Event
Event Description	The following information was received from the state of Kansas via email: A medical event occurred during a Yttrium-90 TheraSphere treatment of a patient's liver cancer. The patient received approximately 24 percent of the dose prescribed in the written directive. There was no harm to the patient other than the inconvenience of rescheduling the treatment to receive the remainder of the dose. [The licensee is] investigating the event and will submit a report within the required 15 days. With this procedure the vial containing the TheraSpheres cannot be viewed due to being inside a lead pig. Therefore, a digital radiation dosimeter is placed near the delivery device. As the dose is delivered to the patient, the readings drop to or near zero. In this case, the technologists and the physician stated the dosimeter was reading 0.0 at the end of the procedure. [The licensee's] immediate corrective action will be for radiation safety staff to verify the instrument readings when the physician feels the entire dose has been delivered. The prescribed dose or quantity was not provided by the State. Kansas NMED Item Number KS170006 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 52864 +/-
Where
University Of Kansas Hospital Authority Kansas City, Kansas (NRC Region 4)
License number:	18-C801
Organization:	Kansas Dept Of Health & Environment
Reporting

Agreement State
Time - Person (Reporting Time:+36.18 h1.508 days <br />0.215 weeks <br />0.0496 months <br />)
Opened:	James Uhlemeyer 17:11 Jul 19, 2017
NRC Officer:	Howie Crouch
Last Updated:	Jul 19, 2017
52864 - NRC Website
v • d • e

v t e Emergency Notification System
University Of Kansas Hospital Authority with Agreement State
WEEKMONTHYEAR2019-12-06T19:28:00 [Table view]
[ENS list for University Of Kansas Hospital Authority]

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