ENS 57649

v t e ENS Event
04:00 Apr 4, 2025
Title	Medical Event
Event Description	The following is a summary of information provided by the North Carolina Radioactive Materials Branch via email: On April 4, 2025, Y-90 SIR-spheres therapeutic split dose administration resulted in a patient being underdosed per the written directive. One of three doses administered was 27 percent or less of the prescribed dose. The referring physician and patient were notified on the same day of treatment. The cause of the underdose was a catheter clog or kink. Corrective actions consisted of retraining of personnel. NC Event Number: 250004 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 57649 +/-
Where
Unc Hospitals Chapel Hill, North Carolina (NRC Region 1)
License number:	068-0565-1
Organization:	Nc Div Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+79.03 h3.293 days <br />0.47 weeks <br />0.108 months <br />)
Opened:	Travis Cartoski 11:02 Apr 7, 2025
NRC Officer:	Jon Lilliendahl
Last Updated:	Apr 7, 2025
57649 - NRC Website
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