ENS 55966

v t e ENS Event
06:00 Jun 24, 2022
Title	Dose Delivered to Wrong Location
Event Description	The following information was received from the state of Colorado via facsimile: On June 24, 2022, a patient was prescribed 1.45 GBq (39.2 mCi) of Y-90 microspheres (TheraSphere) to the right lobe of the liver, lobe estimated size of 474 grams, for a target dose of 148 Gy. However, imaging after the administration indicates that the dose was incorrectly delivered to the left lobe of the liver, lobe estimated size of 283 grams, for an estimated delivered dose of 240 Gy. The preliminary cause is based on the patient's anatomy with the left hepatic branch close to the intended treatment site. The physician's office is reaching out to the patient to notify them but has not been able to at the time of this initial notification. Colorado Event Report ID No.: CO220019 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 55966 +/-
Where
Hca-Healthone, Llc Dba The Medical Center Of Aurora Aurora, Colorado (NRC Region 4)
License number:	CO 305-03
Organization:	Colorado Dept Of Health
Reporting

Agreement State
Time - Person (Reporting Time:+83.12 h3.463 days <br />0.495 weeks <br />0.114 months <br />)
Opened:	Phillip Peterson 17:07 Jun 27, 2022
NRC Officer:	Donald Norwood
Last Updated:	Jun 27, 2022
55966 - NRC Website
v • d • e

v t e Emergency Notification System
Hca-Healthone, Llc Dba The Medical Center Of Aurora with Agreement State
WEEKMONTHYEAR2022-06-24T06:00:00 [Table view]
[ENS list for Hca-Healthone, Llc Dba The Medical Center Of Aurora]

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