ENS Event | |
|---|---|
14:16 Aug 28, 2023 | |
| Title | Agreement State - Medical Underdose |
| Event Description | The following information was provided by the Wisconsin Radiation Protection (the Department) via email:
On August 28, 2023, the Department received a notification from the licensee's radiation safety officer about a Y-90 (Yttrium) Therasphere dose that was not delivered as prescribed to the patient. The procedure occurred at 0916 CDT on August 28, 2023. The written directive stated that the dose delivered should be 175 Gray (Gy). The estimated dose delivered to the liver was 31.7 Gy, 18 percent of the prescribed dose. During the administration, it was identified that the spheres appeared to be clumping. The licensee attempted physical agitation of the line, as well as 8 flushes. The licensee decided to terminate the procedure when it was clear they were not administering the dose as desired. A Therasphere representative was on-site for the administration. The patient was notified and a follow-up procedure is scheduled to deliver the remainder of the dose. The Department will follow up with a site visit to investigate the incident. Wisconsin Event Report ID Number: WI230015 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 | |
|---|---|
| Aurora Health Care Southern Lakes Mount Pleasant, Wisconsin (NRC Region 3) | |
| License number: | 059-1019-01 |
| Organization: | Wisconsin Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+20.48 h0.853 days <br />0.122 weeks <br />0.0281 months <br />) | |
| Opened: | Kyle Walton 10:45 Aug 29, 2023 |
| NRC Officer: | Karen Cotton-Gross |
| Last Updated: | Aug 29, 2023 |
| 56699 - NRC Website | |
Aurora Health Care Southern Lakes with Agreement State | |
WEEKMONTHYEARENS 566992023-08-28T14:16:00028 August 2023 14:16:00
[Table view]Agreement State Agreement State - Medical Underdose 2023-08-28T14:16:00 | |