ENS 54840

v t e ENS Event
04:00 Aug 18, 2020
Title	Agreement State Report - Patient Underdose
Event Description	The following report was received from the Ohio Department of Health via email. On August 14, 2020, the licensee attempted to treat a patient with Y-90 TheraSphere microspheres. Under the guidance of the manufacturer's representative, the AU [Authorized User] performed pre-patient checks on the device, including tubing patency check. After the infusion was started it became apparent the patient was not receiving the dose, and the licensee was unable to clear the blockage in the tubing. The procedure was terminated and the patient and referring physician were notified. Approximately 93% of the activity remained in the device. Static imaging was performed on the patient to determine the dose received. There was no measurable activity in the patient. Ohio Event No.: OH200004 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 54840 +/-
Where
Ohio Department Of Health Columbus, Ohio (NRC Region 3)
License number:	OH-02120250070
Organization:	Ohio Department Of Health
Reporting

Agreement State
Time - Person (Reporting Time:+9.22 h0.384 days <br />0.0549 weeks <br />0.0126 months <br />)
Opened:	Michael Rubadue 13:13 Aug 18, 2020
NRC Officer:	Michael Bloodgood
Last Updated:	Aug 18, 2020
54840 - NRC Website
v • d • e

v t e Emergency Notification System
Ohio Department Of Health with Agreement State
WEEKMONTHYEAR2020-08-18T04:00:00 [Table view]
[ENS list for Ohio Department Of Health]

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