ENS 55630

v t e ENS Event
05:00 Dec 6, 2021
Title	Underdose of Y-90
Event Description	The following was received from the Commonwealth of Pennsylvania by email: On December 6, 2021, a patient underwent a Y-90 TheraSphere treatment. There were no apparent issues during the treatment, but the four-sided equipment readings before and after treatment indicated that only 63% of the prescribed dosage got into the patient. The prescribed dose was 4.08 GBq and the calculated received dose was 2.57 GBq. Preliminarily the licensee believes there was a flow issue and the micro catheter caused some of the material to precipitate out. The licensee is currently investigating to determine if that is the cause. The patient and physician have been informed. No adverse effects to the patient are anticipated. PA Event Report ID No: PA210019 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 55630 +/-
Where
Thomas Jefferson Univ. Hospitals Philadelphia, Pennsylvania (NRC Region 1)
License number:	PA-0130
Organization:	Pa Bureau Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+52.02 h2.168 days <br />0.31 weeks <br />0.0713 months <br />)
Opened:	John Chippo 09:01 Dec 8, 2021
NRC Officer:	Bethany Cecere
Last Updated:	Dec 8, 2021
55630 - NRC Website
v • d • e

v t e Emergency Notification System
Thomas Jefferson Univ. Hospitals with Agreement State
WEEKMONTHYEAR2021-12-06T05:00:00 [Table view]
[ENS list for Thomas Jefferson Univ. Hospitals]

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