ENS 55599

v t e ENS Event
06:00 Nov 19, 2021
Title	Dose Misadministration
Event Description	The following information was received from the state of Wisconsin via email: On November 22, 2021, the Department became aware of a medical event involving Y-90 TheraSphere which occurred on November 19, 2021. A patient had been prescribed two administrations to different segments of the liver of 126 Gy and 138 Gy. However, the licensee has estimated that the administered doses were 256 Gy (103 percent [over]) and 294 Gy (113 percent [over]). The administered doses had been ordered with an incorrect calibration date. A full dose projection is ongoing by the vendor. The State will perform a reactive inspection. Wisconsin event no.: WI210010 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 55599 +/-
Where
Aurora Medical Center Of Oshkosh Oshkosh, Wisconsin (NRC Region 3)
License number:	139-1025-01
Organization:	Wisconsin Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+80.15 h3.34 days <br />0.477 weeks <br />0.11 months <br />)
Opened:	Luther Loehrke 14:09 Nov 22, 2021
NRC Officer:	Brian Lin
Last Updated:	Nov 22, 2021
55599 - NRC Website
v • d • e

v t e Emergency Notification System
Aurora Medical Center Of Oshkosh with Agreement State
WEEKMONTHYEAR2021-06-21T05:00:00 [Table view]
[ENS list for Aurora Medical Center Of Oshkosh]

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