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. 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. |
| 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 | |
University Of Colorado Hospital with Agreement State | |
WEEKMONTHYEARENS 567772023-10-04T06:00:0004 October 2023 06:00:00
[Table view]Agreement State Medical Underdose ENS 565402023-05-24T19:00:00024 May 2023 19:00:00 Agreement State Patient Underdose ENS 565292023-05-18T06:00:00018 May 2023 06:00:00 Agreement State Medical Event (Patient Underdose) ENS 551112021-02-22T19:30:00022 February 2021 19:30:00 Agreement State Lutetium-177 in Stolen Vehicle Recovered ENS 541932019-08-01T21:30:0001 August 2019 21:30:00 Agreement State Agreement State Report - Possible Lost Radioactive Material ENS 528512017-07-12T17:00:00012 July 2017 17:00:00 Agreement State Agreement State Report - Misadministration of Treatment ENS 514702015-10-14T20:30:00014 October 2015 20:30:00 Agreement State Colorado Agreement State Report - Patient Received 40 Percent Less than Prescribed Dose ENS 470432011-07-08T13:30:0008 July 2011 13:30:00 Agreement State Agreement State Report - Medical Event Overexposure to Thyroid Gland 2023-05-24T19:00:00 | |