ENS Event | |
|---|---|
05:00 Sep 1, 2023 | |
| Title | |
| Event Description | The following information was provided by the Wisconsin Radiation Protection (the Department) via email:
On September 1, 2023, the department received a notification from the licensee's radiation safety officer about a Y-90 Therasphere dose that was not delivered as prescribed to the patient. The procedure occurred the morning of September 1, 2023. The written directive stated that the activity administered should be 1.24 GBq. The estimated activity administered to the patient was 0.715 GBq, 57.7 percent of the prescribed activity. During the administration, it was identified that the spheres required increased pressure to deliver, and that the spillover vial collected a high volume of material. Post-procedure surveys confirmed that a large portion of the material had not been administered to the patient. 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. 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 Metro, Inc. Milwaukee, Wisconsin (NRC Region 3) | |
| License number: | 079-1281-01 |
| Organization: | Wisconsin Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+9.92 h0.413 days <br />0.059 weeks <br />0.0136 months <br />) | |
| Opened: | Kyle Walton 14:55 Sep 1, 2023 |
| NRC Officer: | Lawrence Criscione |
| Last Updated: | Sep 1, 2023 |
| 56706 - NRC Website | |
Aurora Health Care Metro, Inc. with Agreement State | |
WEEKMONTHYEARENS 567062023-09-01T05:00:0001 September 2023 05:00:00
[Table view]Agreement State Y-90 Underdose 2023-09-01T05:00:00 | |