ENS 52878

v t e ENS Event
04:00 Jul 28, 2017
Title	Agreement State Report - Dose Received Exceeded Prescribed Dose
Event Description	The following information was received from the State of Florida via email: [The State of Florida] received a call from the [Mayo Clinic] RSO [Radiation Safety Officer] to report a medical event that occurred at Mayo clinic. While performing a 90cc volume liver ablation, a female patient was to receive a 340 Gy dose, but it was later discovered that the dose delivered was 800 Gy. The physician has been notified, and is contacting the patient to inform her of the overdose and verify that there are no unusual side effects. A written report from the RSO will be sent to this office before Aug. 11th detailing the cause of the incident and corrective actions to be taken. Incident Number: FL17-230 The isotope involved is Y-90 [Yttrium-90] Spheres. 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 52878 +/-
Where
Mayo Clinic Jacksonville, Florida (NRC Region 1)
License number:	1812-3
Organization:	Florida Bureau Of Radiation Control
Reporting

Agreement State
Time - Person (Reporting Time:+12 h0.5 days <br />0.0714 weeks <br />0.0164 months <br />)
Opened:	Tim Dunn 16:00 Jul 28, 2017
NRC Officer:	Steve Sandin
Last Updated:	Jul 28, 2017
52878 - NRC Website
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v t e Emergency Notification System
Mayo Clinic with Agreement State
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