ENS 57806

v t e ENS Event
16:18 Jul 8, 2025
Title	Medical Event
Event Description	The following is a summary of information was provided by the licensee via phone: A planned treatment administering three Y-90 microsphere doses resulted in underdoses of greater than 20 percent for all three doses. The start of the treatment was delayed as the treatment room was not available at the scheduled time. Doses were dispensed assuming a treatment time of 0930 CDT, but actual treatments were delayed until 1118, 1156, and 1244 CDT, respectively. The licensee is also investigating a potential complication in establishing intravenous access to the treatment site (liver). Actual doses planned and administered were as follows: First treatment at 1118 CDT: planned 18.9 mCi, actual 14.1 mCi Second treatment at 1156 CDT: planned 13.8 mCi, actual 10.1 mCi Third treatment at 1244 CDT: planned 17.2 mCi, actual 12.0 mCi Initial review by the authorized user has concluded the treatments administered were adequate and no further treatment is planned. The attending physician and patient are being notified. An NRC Region III inspector was on-site and has been notified. 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 57806 +/-
Where
Ssm Health St Charles, Missouri (NRC Region 3)
License number:	24-1159-01
Organization:	Ssm Health
Reporting

10 CFR 35.3045(a)(1)(i)
Time - Person (Reporting Time:+24.52 h1.022 days <br />0.146 weeks <br />0.0336 months <br />)
Opened:	Britta Green 16:49 Jul 9, 2025
NRC Officer:	Robert A. Thompson
Last Updated:	Jul 9, 2025
57806 - NRC Website
v • d • e

v t e Emergency Notification System
Ssm Health with 10 CFR 35.3045(a)(1)(i)
WEEKMONTHYEAR2025-07-08T16:18:00 [Table view]
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