ENS 56254

v t e ENS Event
05:00 Dec 1, 2022
Title	Patient Underdose
Event Description	The following information was provided by the North Carolina Division of Radiation Protection via email: The state of North Carolina Radioactive Materials Branch received a report at 1050 EST on December 2, 2022, from Duke University Medical Center (license number: 032-0247-4) of a possible medical event involving a patient receiving Yttrium-90 therapy for treatment of a liver tumor. The treatment had an intended dosage of 91.6 mCi with a delivered dosage of 54.6 mCi resulting in a 40 percent under dosing that did not appear to involve stasis. The patient and the patient's representative were notified at the time of the treatment and the referring physician was notified the morning of December 2, 2022. The licensee is currently investigating the root cause but initially believes it to be caused by equipment failure. The State is currently investigating and will provide more information as it becomes available. NC Incident No.: NC220015 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 56254 +/-
Where
Duke University Medical Center Durham, North Carolina (NRC Region 1)
License number:	032-0247-4
Organization:	Nc Div Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+33.68 h1.403 days <br />0.2 weeks <br />0.0461 months <br />)
Opened:	Ken Bugaj Jr. 14:41 Dec 2, 2022
NRC Officer:	Bill Gott
Last Updated:	Dec 2, 2022
56254 - NRC Website
v • d • e

v t e Emergency Notification System
Duke University Medical Center with Agreement State
WEEKMONTHYEAR2022-12-01T05:00:00 [Table view]
[ENS list for Duke University Medical Center]

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