ENS 56529

v t e ENS Event
06:00 May 18, 2023
Title	Medical Event (Patient Underdose)
Event Description	The following was received from the Colorado Department of Public Health and Environment via email: On May 19, 2023, the associate radiation safety officer at the University of Colorado Hospital reported a medical event. The event occurred on May 18, 2023, during a Y-90 TheraSphere administration. The licensee reported that during the administration, there was an obstruction in a line/catheter causing the target to only receive 4.6 percent of the intended dose. The authorized user does not believe the obstruction was due to stasis. The prescribed dose for the treatment was 300 Gy (20.06 mCi) and the administered dose was calculated to be 13.87 Gy (0.93 mCi). The licensee is working with the manufacturer, and the exact cause of the obstruction resulting in the medical event is still under investigation. Colorado Event Report Number: CO230012 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 56529 +/-
Where
University Of Colorado Hospital Aurora, Colorado (NRC Region 4)
License number:	CO 828-01
Organization:	Colorado Dept Of Health
Reporting

Agreement State
Time - Person (Reporting Time:+31.82 h1.326 days <br />0.189 weeks <br />0.0436 months <br />)
Opened:	Matt Gift 13:49 May 19, 2023
NRC Officer:	Kerby Scales
Last Updated:	May 19, 2023
56529 - NRC Website
v • d • e

v t e Emergency Notification System
University Of Colorado Hospital with Agreement State
WEEKMONTHYEAR2023-05-24T19:00:00 [Table view]
[ENS list for University Of Colorado Hospital]

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