ENS Event | |
|---|---|
17:00 Aug 20, 2024 | |
| Title | Medical Underdose |
| Event Description | The following information was provided by the Department of Veterans Affairs (VA) via email:
VA Boston Healthcare System, Boston, Massachusetts, which holds Veterans Health Administration (VHA) Permit Number 20-00671-02 under the VA Master Materials License, reported discovery of a medical event to the National Health Physics Program (NHPP) at approximately 1410 CDT, August 20, 2024. A therapeutic administration of Y-90 microspheres (TheraSphere) to the right lobe of a patient's liver was conducted at approximately 1300 EDT on August 20, 2024. Measurements and calculations indicated the patient received about 63 percent of the prescribed activity. The prescribed activity was 42.9 mCi; the administered activity was estimated at 27 mCi. A causal analysis of the medical event is being performed by the medical center. The patient and the referring physician have been notified. Short term harm to the patient is not expected. NHPP plans to perform a reactive inspection to assess causes and regulatory compliance. NHPP will follow up with a written report in accordance with NRC requirements in 10 CFR 35.3045. NHPP has notified the NRC Region III Project Manager, Bryan Parker. 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 | |
|---|---|
| Va Boston Healthcare System Boston, Massachusetts (NRC Region 3) | |
| License number: | 03-23853-01VA |
| Organization: | Va Boston Healthcare System |
| Reporting | |
| 10 CFR 35.3045(a)(1) | |
| Time - Person (Reporting Time:+18.02 h0.751 days <br />0.107 weeks <br />0.0247 months <br />) | |
| Opened: | Clinton Abell 11:01 Aug 21, 2024 |
| NRC Officer: | Jordan Wingate |
| Last Updated: | Aug 21, 2024 |
| 57280 - NRC Website | |
Va Boston Healthcare System with 10 CFR 35.3045(a)(1) | |
WEEKMONTHYEARENS 572802024-08-20T17:00:00020 August 2024 17:00:00
[Table view]10 CFR 35.3045(a)(1) Medical Underdose ENS 404902004-01-30T16:51:00030 January 2004 16:51:00 10 CFR 35.3045(a)(1) Medical Event Due to Administered Dose Exceeding Prescribed Dosage to the Thyroid 2024-08-20T17:00:00 | |