ENS 53591

v t e ENS Event
04:00 Sep 7, 2018
Title	Agreement State Report - Administered Dose Lower than Prescribed Dose
Event Description	The following information was received from the state of North Carolina via email: A patient being treated for liver tumors was prescribed to receive 47.6 mCi of Y-90 microspheres, but instead received only 11.9 mCi (about 25 percent of prescribed). The remainder was in the vial as residual. Because this under-dosing was not due to stasis or emergent patient conditions, and the delivered dose was less than 20 percent of that prescribed, this constitutes a reportable medical event according to the 2016 version (9) of the NRC guidance for Y-90 microspheres. Source: Microspheres Radionuclide: Y-90 Manufacturer: Sirtex Medical Model: Sir-Spheres S/N: Aggregate Investigation is pending for the Medical Event. North Carolina Tracking Number: 180039 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 53591 +/-
Where
Duke University Medical Center Durham, North Carolina (NRC Region 1)
License number:	0247-4
Organization:	Nc Div Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+37.73 h1.572 days <br />0.225 weeks <br />0.0517 months <br />)
Opened:	Travis Cartoski 17:44 Sep 8, 2018
NRC Officer:	Andrew Waugh
Last Updated:	Sep 8, 2018
53591 - NRC Website
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v t e Emergency Notification System
Duke University Medical Center with Agreement State
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