ENS 55186

v t e 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.

ENS 55186 +/-
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
v • d • e

v t e Emergency Notification System
Minnesota Department of Health with Agreement State
WEEKMONTHYEAR		Agreement State Report - Report of Lost Static Eliminator 2023-04-20T05:00:00 [Table view]
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