ENS 56669

v t e ENS Event
05:00 Jul 13, 2023
Title	Medical Underdose
Event Description	The following information was provided by the Wisconsin Department of Health Services (the Department) via email: On August 9, 2023, the Department was notified by the licensee of a yttrium-90 (Y-90) TheraSphere medical event that had occurred on July 13, 2023. The licensee's radiation safety officer performed a records review on August 2, 2023, and identified a written directive indicating a potential underdose to the patient. After confirming that the documentation was correct on August 8, 2023, the licensee determined that a reportable event had occurred. The prescribed activity to the patient was 1.07 GBq. The licensee initially calculated a delivered activity of .86 GBq based on pre- and post-administration surveys. The radiation safety officer was not able to replicate this calculation and determined that the delivered activity was approximately .781 GBq. This is a delivered activity of 72.99 percent. Utilizing the TheraSphere worksheet, the licensee calculated that the patient received 73.4 percent of the prescribed dose. The licensee will be notifying the patient. There is no anticipated harm to the patient, or exposure to any additional individuals. Event Report ID No.: WI230006 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 56669 +/-
Where
Aurora Health Care Central, Inc Sheboygan, Wisconsin (NRC Region 3)
License number:	117-1022-01
Organization:	Wisconsin Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+654.63 h27.276 days <br />3.897 weeks <br />0.897 months <br />)
Opened:	Kyle Walton 11:38 Aug 9, 2023
NRC Officer:	John Russell
Last Updated:	Aug 9, 2023
56669 - NRC Website
v • d • e

v t e Emergency Notification System
Aurora Health Care Central, Inc with Agreement State
WEEKMONTHYEAR2023-07-13T05:00:00 [Table view]
[ENS list for Aurora Health Care Central, Inc]

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