ENS 55571

v t e 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.

ENS 55571 +/-
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
v • d • e

v t e Emergency Notification System
Chi St. Luke'S Baylor College Of Medicine Med Ctr with Agreement State
WEEKMONTHYEAR2021-11-09T06:00:00 [Table view]
[ENS list for Chi St. Luke'S Baylor College Of Medicine Med Ctr]

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