ENS 58005

v t e ENS Event
04:00 Sep 22, 2025
Title	Medical Event
Event Description	The following is a summary of information received from the New York City Department of Health via email: Memorial Sloan Kettering Cancer Center reported a Y-90 TheraSphere treatment to one site in the liver out of four resulting in 20.7 percent less dose than intended. The planned dose to the treatment site was 235 Gy; only 187 Gy was delivered. The treatment involved four vials to be used. Two of the vials were mistakenly switched during the treatment, resulting in the incorrect dose to one location. The patient was informed. New York item number: NY250006 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 58005 +/-
Where
Memorial Sloan Kettering Cancer Center New York, New York (NRC Region 1)
License number:	75-2968-01
Organization:	New York City Bureau Of Rad Health
Reporting

Agreement State
Time - Person (Reporting Time:+751.75 h31.323 days <br />4.475 weeks <br />1.03 months <br />)
Opened:	Erik Finkelstein 11:45 Oct 23, 2025
NRC Officer:	Ian Howard
Last Updated:	Oct 23, 2025
58005 - NRC Website
v • d • e

v t e Emergency Notification System
Memorial Sloan Kettering Cancer Center with Agreement State
WEEKMONTHYEAR2025-09-22T04:00:00 [Table view]
[ENS list for Memorial Sloan Kettering Cancer Center]

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