ENS Event | |
|---|---|
06:00 Nov 9, 2021 | |
| Title | Medical Underdosage |
| Event Description | The following was received from the Texas Department of State Health Services (the Agency):
On November 10, 2021, the Agency received notification from [the Radiation Safety Officer] RSO of the licensee reporting that a yttrium-90 TheraSphere administration with an intended activity of 44.8 mCi (120 Gy) to be inserted resulted in only 18.7 mCi inserted into the patient with the remainder still in the delivery system. RSO reported the procedure was completed indicating there was no stoppage due to patient or otherwise intervention. This was 41.6 percent of the prescribed activity inserted into the patient and at present an unknown dose. The target was a tumor in the liver. A survey of the room was done with no contamination found. Texas Incident: I-9895 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 | |
|---|---|
| Chi St. Luke'S Baylor College Of Medicine Med Ctr Houston, Texas (NRC Region 4) | |
| License number: | 06661 |
| Organization: | Texas Dept Of State Health Services |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+53.92 h2.247 days <br />0.321 weeks <br />0.0739 months <br />) | |
| Opened: | Randall Redd 11:55 Nov 11, 2021 |
| NRC Officer: | Jeffrey Whited |
| Last Updated: | Nov 11, 2021 |
| 55571 - NRC Website | |
Chi St. Luke'S Baylor College Of Medicine Med Ctr with Agreement State | |
WEEKMONTHYEARENS 555712021-11-09T06:00:0009 November 2021 06:00:00
[Table view]Agreement State Medical Underdosage 2021-11-09T06:00:00 | |