ENS 57556

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v t e ENS Event
05:00 Feb 14, 2025
Title	Medical Event
Event Description	The following information was received from the Massachusetts Radiation Control Program (the Agency) via email: On 02/14/25, at 0549 EST, the licensee, Beth Israel Deaconess Medical Center reported a medical event involving Yttrium-90 Theraspheres (Nordion BWXT ITG Canada, Inc. Model TheraSphere Y-90 Glass Microsphere System, SSD 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 2/14/2025. The patient received two doses. For the first dose, the activity delivered was calculated to be 58.4 percent of the prescribed activity (prescribed activity: 1.84 GBq, delivered activity: 1.075 GBq). For the second dose, the activity delivered was calculated to be 68.6 percent of the prescribed activity (prescribed activity: 0.8 GBq, delivered activity: 0.549 GBq). The event was identified on 2/14/25. The licensee did not report if there were any adverse effects on the patient. The licensee did not report whether the authorized user, referring physician, and patient have been notified. The Agency will follow up with the licensee radiation safety officer to determine the event cause and corrective actions. This is the second medical event during this week involving Theraspheres from this licensee. The licensee has ceased Therasphere procedures at the facility. The Agency considers this event open. The Agency 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 57556 +/-
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:+100.52 h4.188 days <br />0.598 weeks <br />0.138 months <br />)
Opened:	Robert Locke 09:31 Feb 18, 2025
NRC Officer:	Kerby Scales
Last Updated:	Feb 18, 2025
57556 - 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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