ENS 53904

v t e ENS Event
06:00 Feb 28, 2019
Title	Agreement State Report - Underdose of Therasphere Y-90 Treatment
Event Description	The following report was received from the Kentucky Department of Public Health via email: The University of Kentucky RSO [Radiation Safety Officer] reports a patent delivery system failed to deliver part of a TheraSphere Y-90 treatment on February 28, 2019. A patient written directive indicated a prescribed dose of 208 Gy. The patient only received 145 Gy. The RSO indicated the first vial of Y-90 was administered without difficulty. The second vial failed to empty into the administration catheter. Calls were placed to the drug representative and unsuccessful attempts made to administer the remainder of the dose. Patient treatment was stopped with only partial dose delivery. At the time of the report, March 1, 2019, the University is establishing the reason for the administration failure. The patient had been notified and the physician and referring physician are being notified. The university plans an update in 15 days. Kentucky Event Report ID No.: Ky190002. 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 53904 +/-
Where
University Of Kentucky (Hospital) Lexington, Kentucky (NRC Region 1)
License number:	202-049-22
Organization:	Kentucky Dept Of Radiation Control
Reporting

Agreement State
Time - Person (Reporting Time:+31.88 h1.328 days <br />0.19 weeks <br />0.0437 months <br />)
Opened:	Angela Wilbers 13:53 Mar 1, 2019
NRC Officer:	Caty Nolan
Last Updated:	Mar 1, 2019
53904 - NRC Website
v • d • e

v t e Emergency Notification System
University Of Kentucky (Hospital) with Agreement State
WEEKMONTHYEAR2019-02-28T06:00:00 [Table view]
[ENS list for University Of Kentucky (Hospital)]

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