ENS 53901

v t e ENS Event
20:00 Feb 28, 2019
Title	Agreement State Report - Medical Misadministration
Event Description	The following was received via email from the state of Colorado: At approximately 1438 MST on February 28, 2019 the RSO [Radiation Safety Officer] for CO 152-01, St. Anthony Hospital - Centura Health, notified the Department [Colorado Department of Public Health and Environment] of a Y-90 SIR-Sphere misadministration. The procedure occurred at approximately 1300 MST and it was determined that 65 percent of the prescribed dose was delivered to the patient. The RSO noted that during the procedure there were issues with the delivering catheter. During the procedure, the catheter was replaced. A department investigation will occur in the near future. A written report per section 7.21.4 is expected within 15 days. Colorado Event Report ID No.: CO190003 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 53901 +/-
Where
St. Anthony Hospital - Centura Health Lakewood, Colorado (NRC Region 4)
License number:	CO152-01
Organization:	Colorado Dept Of Health
Reporting

Agreement State
Time - Person (Reporting Time:+-2.75 h-0.115 days <br />-0.0164 weeks <br />-0.00377 months <br />)
Opened:	Ramon Li 17:15 Feb 28, 2019
NRC Officer:	Ossy Font
Last Updated:	Feb 28, 2019
53901 - NRC Website
v • d • e

v t e Emergency Notification System
St. Anthony Hospital - Centura Health with Agreement State
WEEKMONTHYEAR2019-02-28T20:00:00 [Table view]
[ENS list for St. Anthony Hospital - Centura Health]

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