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. |
| 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 | |
Memorial Hermann Health System with Agreement State | |
WEEKMONTHYEARENS 556082021-11-23T06:00:00023 November 2021 06:00:00
[Table view]Agreement State Underdose of Patient Medical Event ENS 543272019-10-11T05:00:00011 October 2019 05:00:00 Agreement State Agreement State Report - Misadministration of Y-90 Microspheres 2021-11-23T06:00:00 | |