ENS 55152

v t e ENS Event
04:00 Jun 12, 2019
Title	Failure to Report Underdose to Patient
Event Description	The following was received from the state of Ohio via email: During a routine inspection an unreported medical event [that occurred in 2019] involving Yttrium-90 'SirSpheres' was discovered. During patient treatment the licensee encountered increasing resistance to the delivery of the microspheres, leading the licensee to believe the patient had reached stasis. After further investigation the licensee determined the cause of the resistance was clogging of the microcatheter. The dose delivered to the patient was 79.2 percent of the prescribed dose. A subsequent treatment was given to the patient to make up for the underdose. At the time the licensee's procedures did not consider this as a reportable event. The reportable event procedures have been updated. Ohio Item Number: OH210001 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 55152 +/-
Where
University Hospitals Of Cleveland Cleveland, Ohio (NRC Region 3)
License number:	02110180077
Organization:	Ohio Bureau Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+15636.32 h651.513 days <br />93.073 weeks <br />21.419 months <br />)
Opened:	Michael J Rubadue 16:19 Mar 24, 2021
NRC Officer:	Thomas Herrity
Last Updated:	Mar 24, 2021
55152 - NRC Website
v • d • e

v t e Emergency Notification System
University Hospitals Of Cleveland with Agreement State
WEEKMONTHYEAR2019-06-12T04:00:00 [Table view]
[ENS list for University Hospitals Of Cleveland]

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