ENS 54788

v t e ENS Event
04:00 Jul 17, 2020
Title	Agreement State Report - Underdose Administered to Patient
Event Description	The following was reported by the Florida Bureau of Radiation Control: On 7/17/2020 during ablative treatment with Y-90 TheraSpheres to the male patient, it was discovered that only a partial treatment was administered to the patient. 511.6 Gy was prescribed, 358.9 Gy was delivered, for a 70% delivery rate. The event was discovered during a routine check of waste activity. The Radiation Safety Officer (RSO) reports that from initial information from the tech, all procedures were followed. No abnormal events were noted during the procedure. The prescribing physician and patient have been notified. Clinical outcome is expected to be ok. The RSO will phone in more details on Monday as he was working remotely on Friday. A fifteen day letter will follow. Licensing and Technology will be tasked to investigate. FL incident number: FL20-082 Notified RI and NMSS Events Notification. 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 54788 +/-
Where
Florida Bureau Of Radiation Control Jacksonville, Florida (NRC Region 1)
License number:	1812-3
Organization:	Florida Bureau Of Radiation Control
Reporting

Agreement State
Time - Person (Reporting Time:+13.33 h0.555 days <br />0.0793 weeks <br />0.0183 months <br />)
Opened:	John Williamson 17:20 Jul 17, 2020
NRC Officer:	Thomas Herrity
Last Updated:	Jul 17, 2020
54788 - NRC Website
v • d • e

v t e Emergency Notification System
Florida Bureau of Radiation Control with Agreement State
WEEKMONTHYEAR	Agreement State Report - Vehicle Carrying Radio-Pharmaceuticals Involved in Accident	Agreement State Report - Lost/Stolen Troxler Gauge	Agreement State Report - Leaking Sealed Source	2020-09-04T04:00:00 [Table view]
[ENS list for Florida Bureau of Radiation Control]

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