ENS 54427

v t e ENS Event
19:28 Dec 6, 2019
Title	Agreement State Report - Dose Delivered Differed by More than 20 Percent
Event Description	The following was received from the Kansas Department of Health and Environment via email: On December 6, 2019, at 1328 [CST], [the University of Kansas Hospital Authority] reported a medical event involving Y-90 Microspheres to the Kansas Radiation Control Program (RCP). The licensee stated that the patient had unusually small blood vessel feeding the tumor and prevented a larger than anticipated dose to the tumor. An initial written report was received at 1354 [CST] from the RSO [Radiation Safety Officer] stating that there were no errors or problems during the procedure administration. The dose differed by more than 20 percent, though the physician stated that the dose was therapeutic and will not plan to retreat. There was no report of contamination at the facility or of the patient. The Kansas RCP is preparing for an onsite investigation to review the incident. That investigation will be the basis for a final NMED report to follow. 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 54427 +/-
Where
University Of Kansas Hospital Authority Topeka, Kansas (NRC Region 4)
License number:	18-C800
Organization:	Kansas Dept Of Health & Environment
Reporting

Agreement State
Time - Person (Reporting Time:+-3.92 h-0.163 days <br />-0.0233 weeks <br />-0.00537 months <br />)
Opened:	David M Lawrenz 15:33 Dec 6, 2019
NRC Officer:	Ossy Font
Last Updated:	Dec 6, 2019
54427 - NRC Website
v • d • e

v t e Emergency Notification System
University Of Kansas Hospital Authority with Agreement State
WEEKMONTHYEAR2019-12-06T19:28:00 [Table view]
[ENS list for University Of Kansas Hospital Authority]

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