ENS 54876

v t e ENS Event
04:00 Aug 27, 2020
Title		Agreement State Report - Incorrect Dose Delivered to Patient
Event Description	The following was received from the Ohio Department of Health: The licensee tried to perform a split dose procedure on the right lobe anterior and right lobe posterior portion of a patient's liver. The prescribed dose was 60 mCi Y-90 Theraspheres (approximately 150 Gy) for each site. The posterior was treated first and then the catheter was moved to the anterior position. Post treatment scans of the patient indicated the posterior received 20 mCi (35 Gy) and the anterior received 100 mCi (180 Gy). The physician believes the catheter slipped after initial placement, resulting in an overdose to the anterior and underdose to the posterior. The licensee will no longer conduct spilt dose procedures. Ohio Item Number: OH200006 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 54876 +/-
Where
Ohio Bureau Of Radiation Protection Cleveland, Ohio (NRC Region 3)
License number:	02110180077
Organization:	Ohio Bureau Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+175.22 h7.301 days <br />1.043 weeks <br />0.24 months <br />)
Opened:	Michael J. Rubadue 11:13 Sep 3, 2020
NRC Officer:	Thomas Herrity
Last Updated:	Sep 3, 2020
54876 - NRC Website
v • d • e

v t e Emergency Notification System
Ohio Bureau of Radiological Health and Safety with Agreement State
WEEKMONTHYEAR	Agreement State Report - Stolen Troxler Gauge	Agreement State Report - Leaking Source	Agreement State Report - Shutter Mechanism Malfunction	Agreement State Report - Incorrect Dose Delivered to Patient 2020-09-29T11:30:00 [Table view]
[ENS list for Ohio Bureau of Radiological Health and Safety]

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