ENS 56601

v t e ENS Event
17:01 Jun 29, 2023
Title	Medical Event - Patient Underdose
Event Description	The following information was provided by the licensee via phone and followed up with an email: Yesterday, June 29, 2023, from 1201 to 1314 CDT, a Therasphere procedure was performed on a patient. The prescribed dose was for 14.58 mCi of Yttrium-90 (Y-90) to the left lobe of the liver. The authorized user (AU) stated that everything seemed to go normally other than they remembered afterwards a little more resistance than usual while performing the injection. The patient was sent for imaging and it was discovered shortly after 1500 that there was no dose in the patient. This was investigated, and the dose was found to be in the tubing. It is believed that the radioactive particles got clogged within the catheter. The AU stated that the catheter used was a model Trinav 120 cm length catheter, which is a special catheter with anti-reflux basket to prevent reflux and specially designed for Y-90 delivery. The AU stated that they would inform the patient of the medical event on the morning of June 30, 2023 (today). Additional details will be provided in the 15-day written report. 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 56601 +/-
Where
Saint Louis University St. Louis, Missouri (NRC Region 3)
License number:	24-00196-07
Organization:	Saint Louis University
Reporting

10 CFR 35.3045(a)(1)
Time - Person (Reporting Time:+19.23 h0.801 days <br />0.114 weeks <br />0.0263 months <br />)
Opened:	Kevin Ferguson 12:15 Jun 30, 2023
NRC Officer:	Eric Simpson
Last Updated:	Jun 30, 2023
56601 - NRC Website
v • d • e

v t e Emergency Notification System
Saint Louis University with 10 CFR 35.3045(a)(1)
WEEKMONTHYEAR2023-06-29T17:01:00 [Table view]
[ENS list for Saint Louis University]

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