ENS Event | |
|---|---|
04:00 Jul 25, 2025 | |
| Title | Medical Event |
| Event Description | The following information was provided by the Florida Bureau of Radiation Control (BRC) via email:
BRC was notified on 7/28/25 that on Friday, 7/25/25, a patient at Advent Health, Daytona was receiving Y-90 TheraSphere treatment for the liver. The patient received a dose which differed by more than 20 percent from the prescribed dose. Treatment was provided in 2 segments, denoted in 2 scripts. One segment received the full prescribed treatment, while the other segment received 51 percent of the intended treatment. Due to the treatment being provided as 2 scripts, treatment two differed by more than 20 percent. The [licensee's] radiation safety officer states that the dosimeter on the vial showed a dose of 0, but when all administration materials were removed, the residual within the equipment was much higher than expected. The primary care provider has been informed. It is unknown if the patient has been informed. 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 | |
|---|---|
| Adventist Health Systems Altamont Springs, Florida (NRC Region 1) | |
| License number: | 2897-1 |
| Organization: | Florida Bureau Of Radiation Control |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+85.38 h3.558 days <br />0.508 weeks <br />0.117 months <br />) | |
| Opened: | Monroe A. Cooper 17:23 Jul 28, 2025 |
| NRC Officer: | Ernest West |
| Last Updated: | Jul 28, 2025 |
| 57830 - NRC Website | |
Adventist Health Systems with Agreement State | |
WEEKMONTHYEARENS 578302025-07-25T04:00:00025 July 2025 04:00:00
[Table view]Agreement State Medical Event ENS 578432025-07-08T04:00:0008 July 2025 04:00:00 Agreement State Lost Source ENS 502952014-06-26T04:00:00026 June 2014 04:00:00 Agreement State Agreement State Report Involving an Unintended Dose to a Fetus 2025-07-08T04:00:00 | |