ENS 55869

v t e ENS Event
05:00 Jun 21, 2021
Title	Medical Event Due to Discrepency with Written Directive
Event Description	The following summary was received from the Wisconsin Department of Public Health (the Department) via email: On April 28, 2022, during an inspection, the Department became aware of a medical event involving Y-90 TheraSphere which occurred on June 21, 2021. A patient's procedure planned for two vials and an activity of 2.81 GBq, which were administered. The written directive erroneously only accounted for one vial and a prescribed activity of 1.94 GBq; therefore, the administered activity was 138.4 percent of the activity specified on the written directive. The administered activity was within 2 percent of the planned activity. Wisconsin Event Report ID No.: WI220010 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 55869 +/-
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:+7493.12 h312.213 days <br />44.602 weeks <br />10.264 months <br />)
Opened:	Luther S. Loehrke 10:07 Apr 29, 2022
NRC Officer:	Ossy Font
Last Updated:	Apr 29, 2022
55869 - 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]

Navigation menu