ENS 54672

v t e ENS Event
04:00 Apr 16, 2020
Title	Underdose to Patient
Event Description	The following is a summary of information received via telephone: On April 16, 2020, a patient received 11.5 percent of the prescribed dose of Y-90 TheraSphere therapy to the left liver. It is believed that the delivery device malfunctioned as the technician experienced increased pressure in the line when pushing the TheraSphere into the caster. The therapy was aborted after a few failed attempts. The intended dose was 97.3 milliCuries of Y-90. The patient is aware and will be returning for the remainder of the dose. The licensee contacted the vendor who will discard the malfunctioned device. 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 54672 +/-
Where
Christiana Care Health Services Wilmington, Delaware (NRC Region 1)
License number:	07-12153-02
Organization:	Christiana Care Health Services
Reporting

10 CFR 35.3045(a)(1)
Time - Person (Reporting Time:+32.62 h1.359 days <br />0.194 weeks <br />0.0447 months <br />)
Opened:	Karol Wen 12:37 Apr 17, 2020
NRC Officer:	Caty Nolan
Last Updated:	Apr 17, 2020
54672 - NRC Website
v • d • e

v t e Emergency Notification System
Christiana Care Health Services with 10 CFR 35.3045(a)(1)
WEEKMONTHYEAR2020-04-16T04:00:00 [Table view]
[ENS list for Christiana Care Health Services]

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