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. |
| 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 | |
Memorial Sloan Kettering Cancer Center with Agreement State | |
WEEKMONTHYEARENS 580052025-09-22T04:00:00022 September 2025 04:00:00
[Table view]Agreement State Medical Event ENS 573412024-09-24T04:00:00024 September 2024 04:00:00 Agreement State Medical Misadministration ENS 519922015-01-16T04:00:00016 January 2015 04:00:00 Agreement State Agreement State Report - Medical Underdose 2025-09-22T04:00:00 | |