ENS Event | |
|---|---|
05:00 Apr 1, 2021 | |
| Title | Dose Administered Greater than Prescribed |
| Event Description | The following was received from the Minnesota Department of Health via email:
A medical event has occurred at Essentia Health, Duluth, MN (MN license number 1048). The event occurred on April 1, 2021 and was discovered by the radiation safety officer on April 8, 2021. The licensee reported the event to the state of Minnesota on April 8, 2021. Preliminary details are as follows: A Y-90 Theraspheres procedures with a prescribed dose of 140 Gy administered 173.4 Gy on April 1, 2021. This resulted in a dose [that varied by] greater than 20 percent of prescribed. The event was discovered by the radiation safety officer following a records review and reported to the state of Minnesota within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> of discovery. The licensee is investigating the root cause and the potential for harm to the patient. A report will be submitted within 15 days. The state plans to do an on-site investigation with the licensee. Additional information will be reported following the final report from the licensee and investigation by the state. 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. |
| Where | |
|---|---|
| Minnesota Department Of Health Duluth, Minnesota (NRC Region 3) | |
| License number: | 1048 |
| Organization: | Minnesota Department Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+203.13 h8.464 days <br />1.209 weeks <br />0.278 months <br />) | |
| Opened: | Sherrie Flaherty 16:08 Apr 9, 2021 |
| NRC Officer: | Ossy Font |
| Last Updated: | Apr 9, 2021 |
| 55186 - NRC Website | |
Minnesota Department of Health with Agreement State | ||
WEEKMONTHYEARENS 564932023-04-20T05:00:00020 April 2023 05:00:00 Agreement State Found Source ENS 551862021-04-01T05:00:0001 April 2021 05:00:00 Agreement State Dose Administered Greater than Prescribed ENS 549332020-10-05T05:00:0005 October 2020 05:00:00 Agreement State | Agreement State Report - Report of Lost Static Eliminator ENS 545142020-02-02T06:00:0002 February 2020 06:00:00 Agreement State Agreement State Report - Medical Event 2023-04-20T05:00:00 [Table view] | |