ENS 54181

v t e ENS Event
04:00 Jun 27, 2019
Title	Agreement State Report - Underdose to the Liver
Event Description	The following information is summarized from an email received from the state of Ohio: A patient was undergoing Y-90 Therasphere treatment of both lobes of the liver. The calculations and dose were ordered for the volume of the left lobe which was 230cc. Due to a communication error, that dose was delivered to the right lobe which had a volume of 1600cc. This represents an underdose to the right lobe. The intended dose to the right lobe was 120 Gy. The delivered dose was 17.6 Gy. The licensee is evaluating additional treatment. The patient and prescribing physician were notified. The State will be performing an investigation. Ohio report no.: OH190013 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 54181 +/-
Where
Genesis Hospital Zanesville, Ohio (NRC Region 3)
License number:	02120610006
Organization:	Ohio Bureau Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+654.62 h27.276 days <br />3.897 weeks <br />0.897 months <br />)
Opened:	Michael Snee 10:37 Jul 24, 2019
NRC Officer:	Howie Crouch
Last Updated:	Jul 24, 2019
54181 - NRC Website
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v t e Emergency Notification System
Genesis Hospital with Agreement State
WEEKMONTHYEAR2021-07-14T04:00:00 [Table view]
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