ENS 56777

v t e ENS Event
06:00 Oct 4, 2023
Title	Medical Underdose
Event Description	The following information was provided by the Colorado Department of Public Health and Environment (the Agency) via email: On October 4, 2023, the radiation safety officer of the University of Colorado Hospital reported a medical event to the emergency response line. The medical event occurred during the administration of a Y-90 TheraSphere treatment that took place that day. The authorized user stated that high back pressure was observed during administration so only 71.2 percent of the prescribed dose was delivered to the treatment area. This is the third medical event (May 18, 2023 - CO230012 and May 24, 2023 - CO230014) with Y-90 TheraSpheres at this facility in the last six months. Different authorized users and IR [Interventional Radiology] technologists were present at each medical event. The Agency is currently waiting for additional information from the hospital and the Agency intends to follow up with an in-person investigation. Event Report ID No.: CO2300034 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 56777 +/-
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:+28.23 h1.176 days <br />0.168 weeks <br />0.0387 months <br />)
Opened:	Meghan Cromie 10:14 Oct 5, 2023
NRC Officer:	Ian Howard
Last Updated:	Oct 5, 2023
56777 - 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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