ENS 56500

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v t e ENS Event
01:56 May 2, 2023
Title	Medical Underdose
Event Description	The following information was provided by the Oregon Health Authority via email: Upon completion of [Yttrium] Y-90 Therasphere delivery [to a patient] and completion of post-treatment template measurements, it was noted that the delivery ratio appeared to be below 80%. The technologist who was involved in delivery contacted the authorized user who came and reviewed the information. Both the authorized user and Boston Scientific representative, who was present during delivery, felt that an error had been made in post-treatment measurements, so they were repeated both that day and the following. Nuclear medicine staff performed [single photon emission computed tomography with a computed tomography] SPECT/CT imaging of the Nalgene container. This imaging was reviewed on 5/1/23 and it was determined that activity was remaining in the delivery set tubing. Imaging was reviewed with the Assistant [radiation safety officer] RSO, and it was determined that a Medical Event had occurred. Per [the assistant RSO], the Medical Event was reported to the Oregon Health Authority on 5/2/23. The Authorized User, communicated the situation with the patient and is confident that no adverse effect has occurred based on calculated treatment thresholds and tumor burden. The authorized user reviewed the SPECT/CT imaging and will participate in mitigation. 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 56500 +/-
Where
Sacred Heart Medical Center Springfield, Oregon (NRC Region 4)
License number:	90270
Organization:	Or Dept Of Health Rad Protection
Reporting

Agreement State
Time - Person (Reporting Time:+17.4 h0.725 days <br />0.104 weeks <br />0.0238 months <br />)
Opened:	Hillary Haskins 19:20 May 2, 2023
NRC Officer:	John Russell
Last Updated:	May 2, 2023
56500 - NRC Website
v • d • e

v t e Emergency Notification System
Sacred Heart Medical Center with Agreement State
WEEKMONTHYEAR2023-05-02T01:56:00 [Table view]
[ENS list for Sacred Heart Medical Center]

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ENS Notification