ENS 55608

v t e ENS Event
06:00 Nov 23, 2021
Title	Underdose of Patient Medical Event
Event Description	The following was received from the state of Texas (the Agency) via email: On November 24, 2021, the licensee notified the Agency that a medical event had occurred at its facility on November 23, 2021. A patient was being treated with SIRTEX SIR-spheres yttrium-90 microspheres. The order for the treatment was 8.1 millicuries. Following the procedure, it was determined the patient had only received 6.3 millicuries. The licensee reported this was not the result of stasis and is investigating to determine the cause. The licensee has contacted the manufacturer. The Authorized User stated the dose delivered should be high enough for an effective treatment. An investigation into this event is ongoing. More information will be provided as it is obtained in accordance with SA-300. Texas Incident Number: 9896 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 55608 +/-
Where
Memorial Hermann Health System Houston, Texas (NRC Region 4)
License number:	L00650
Organization:	Texas Dept Of State Health Services
Reporting

Agreement State
Time - Person (Reporting Time:+32.68 h1.362 days <br />0.195 weeks <br />0.0448 months <br />)
Opened:	Karen Blanchard 14:41 Nov 24, 2021
NRC Officer:	Lloyd Desotell
Last Updated:	Nov 24, 2021
55608 - NRC Website
v • d • e

v t e Emergency Notification System
Memorial Hermann Health System with Agreement State
WEEKMONTHYEAR2021-11-23T06:00:00 [Table view]
[ENS list for Memorial Hermann Health System]

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