ENS 53473

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v t e ENS Event
04:00 Jun 25, 2018
Title	Agreement State Report - Underdose of Y-90 Theraspheres
Event Description	The following information was obtained from New York City Department of Health and Mental Hygiene, Office of Radiological Health via email: On June 25, 2018, a 65-year old male patient was treated with Y90 TheraSphere to the right side of the liver. The intended dose of administration was 64.8 mCi (2.4 GBq). Upon conclusion of the procedure, when the waste materials (delivery line, vial, gauze, etc.) was counted, it was found that 41.87 mCi (1.55 GBq) of Y90 TheraSphere was actually administered to the patient. In other words patient received 64.6% of intended dose. The Radiation Safety Office of Mount Sinai Hospital reported the incident to the New York City Department of Health and Mental Hygiene [NYCDOH] on 6/25/2018 at 1340 hrs. These findings were communicated to the patient and the referring physician within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />. The licensee stated that no serious adverse events occurred and the patient will be followed up with Interventional Radiology as per protocol. The licensee indicated that the root cause analysis of the event is currently being performed and a detailed report of the event with corrective action will be sent to the NYCDOH within 15 days. 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 53473 +/-
Where
Icahn School Of Medicine At Mount Sinai New York City, New York (NRC Region 1)
License number:	75-2909-04
Organization:	New York City Bureau Of Rad Health
Reporting

Agreement State
Time - Person (Reporting Time:+28.27 h1.178 days <br />0.168 weeks <br />0.0387 months <br />)
Opened:	Hailu Tedla 08:16 Jun 26, 2018
NRC Officer:	Howie Crouch
Last Updated:	Jun 26, 2018
53473 - NRC Website
v • d • e

v t e Emergency Notification System
Icahn School Of Medicine At Mount Sinai with Agreement State
WEEKMONTHYEAR2018-06-25T04:00:00 [Table view]
[ENS list for Icahn School Of Medicine At Mount Sinai]

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