ENS 57341

v t e ENS Event
04:00 Sep 24, 2024
Title	Medical Misadministration
Event Description	The following information was provided by the New York State Department of Health via phone and email: Notification was received by phone call on 9/24/24 and email on 9/26/24, from Memorial Sloan Kettering Cancer Center, NYC license number 75-2968-01, of an event that took place (or was discovered) on 9/24/24. They say the event involved a Y-90 microsphere procedure with a dose to a site other than the treatment site that exceeded 0.5 Sv and was 50 percent or more in excess of the dose expected. The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: The unintended dose was to the stomach and duodenum. The estimated excess dose to the affected tissue was 99 Gy. This information is tentative pending further investigation. NYC Event Number: NYC-24-0924 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 57341 +/-
Where
Memorial Sloan Kettering Cancer Center New York, New York (NRC Region 1)
License number:	75-2968-01
Organization:	New York State Dept. Of Health
Reporting

Agreement State
Time - Person (Reporting Time:+55.02 h2.293 days <br />0.327 weeks <br />0.0754 months <br />)
Opened:	Erik Finkelstein 11:01 Sep 26, 2024
NRC Officer:	Ian Howard
Last Updated:	Sep 26, 2024
57341 - NRC Website
v • d • e

v t e Emergency Notification System
Memorial Sloan Kettering Cancer Center with Agreement State
WEEKMONTHYEAR2025-09-22T04:00:00 [Table view]
[ENS list for Memorial Sloan Kettering Cancer Center]

Navigation menu