ENS 56237

v t e ENS Event
06:00 Nov 21, 2022
Title	Underdose of YTTRIUM-90 SIR-SPHERES
Event Description	The following information was provided by the Texas Department of State Health Services (the Department) via email: On November 23, 2022, the Department was notified by a licensee of a medical event involving Yttrium-90 Sir-Spheres. The procedure took place on November 21 and was thought to occur without incident, but when the tubing was measured on November 22, they found significant activity indicating that only 61.6 percent of the intended activity or material had been inserted into the patient. The intended activity to be inserted was 13.4 mCi and the actual activity delivered was 8.26 mCi. The room was surveyed after the procedure and no significant leakage or contamination was found. The patient and prescribing physician should be notified today. Further information will be supplied per SA-300. The investigation is ongoing. Texas Incident Number: 9965 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 56237 +/-
Where
Chi St Lukes Health Baylor Houston, Texas (NRC Region 4)
License number:	L06661
Organization:	Texas Dept Of State Health Services
Reporting

Agreement State
Time - Person (Reporting Time:+53.5 h2.229 days <br />0.318 weeks <br />0.0733 months <br />)
Opened:	Randall Redd 11:30 Nov 23, 2022
NRC Officer:	Ernest West
Last Updated:	Nov 23, 2022
56237 - NRC Website
v • d • e

v t e Emergency Notification System
Chi St Lukes Health Baylor with Agreement State
WEEKMONTHYEAR2022-11-21T06:00:00 [Table view]
[ENS list for Chi St Lukes Health Baylor]

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