ENS 57546

v t e ENS Event
05:00 Feb 11, 2025
Title	Medical Event
Event Description	The following information was provided by the Massachusetts Radiation Control Program (MRCP) via email: On 02/13/25, at 1138 EST, the licensee, Beth Israel Deaconess Medical Center (Massachusetts license number: 60-0432) reported a medical event involving yttrium-90 Theraspheres (Manufacturer: Nordion BWXT ITG Canada, Inc.; Model: TheraSphere Y-90 glass microsphere system; sealed source and device registration number: NR-0220-D-131-S). The total administered activity differed from prescribed treatment activity as documented in the written directive by 20 percent or more. The medical event occurred on 2/11/25. The activity delivered was calculated to be 45.5 percent of the prescribed activity (prescribed activity: 4.13 GBq, delivered activity: 1.88 GBq). The event was identified on 2/12/25. The licensee reported that there was no adverse effect on the patient. The authorized user, referring physician, and patient have been notified. MRCP will follow up with the licensee's radiation safety officer (RSO) to determine event cause and corrective actions. The device has been taken out of service while the investigation remains open. The MRCP considers this event open. The MRCP will follow up with a special inspection of the licensee. 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 57546 +/-
Where
Beth Israel Deaconess Medical Center Boston, Massachusetts (NRC Region 1)
License number:	60-0432
Organization:	Ma Radiation Control Program
Reporting

Agreement State
Time - Person (Reporting Time:+78.62 h3.276 days <br />0.468 weeks <br />0.108 months <br />)
Opened:	Bob Locke 11:37 Feb 14, 2025
NRC Officer:	Ernest West
Last Updated:	Feb 14, 2025
57546 - NRC Website
v • d • e

v t e Emergency Notification System
Beth Israel Deaconess Medical Center with Agreement State
WEEKMONTHYEAR2025-02-14T05:00:00 [Table view]
[ENS list for Beth Israel Deaconess Medical Center]

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