ENS 56540

v t e ENS Event
19:00 May 24, 2023
Title	Patient Underdose
Event Description	The following information was provided by the Colorado Department of Health via email: On May 24, 2023, the Radiation Safety Officer of the University of Colorado Hospital (RAML [Radioactive Material License] 828-01) reported a medical event. The medical event occurred during the administration of Y-90 TheraSphere treatment that took place in the afternoon on Wednesday, May 24, 2023. During the administration, there appeared to be an obstruction in the catheter's line preventing the target from receiving the intended dose. The obstruction was noticed early in the procedure and it's estimated only 5 to10 percent of dose went to the target organ. After the obstruction was observed, the catheter was removed from the patient and the rest of the dose was not administered. This event is similar to an event at the same hospital on May 18, 2023 (CO230012) which occurred with a different AU [authorized user]. The TheraSpheres were from the same batch. The licensee is pausing Therasphere administrations from the same lot number. We are still waiting on additional information from the hospital about the investigation. Event Report ID No.: CO230014 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 56540 +/-
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:+21.67 h0.903 days <br />0.129 weeks <br />0.0297 months <br />)
Opened:	Heather Gilbert 16:40 May 25, 2023
NRC Officer:	Ian Howard
Last Updated:	May 25, 2023
56540 - 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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