ENS 58064

v t e ENS Event
05:00 Nov 25, 2025
Title	Medical Event
Event Description	The following information was provided by the Ohio Bureau of Radiation Protection via email: A patient was scheduled to receive 30 mCi Y-90 to the right lobe of the liver in segments 5/6, but only 11.2 mCi was delivered. This is an underdose of 63 percent. The authorized user (AU) and interventional radiologist physician verified catheter placement by contrast injection and fluoroscopy prior to the procedure and continued to monitor the catheter position during the treatment. During the procedure, the AU noted that saline was leaking from the top of the acrylic vial holder inside the delivery box and that there was insufficient pressure to mix/suspend the microspheres in the dose vial. It was also noted the catheter had moved from the original target. The AU determined the dose could not be delivered as prescribed and abandoned the procedure. The patient and referring physician were notified. Investigation is pending. Ohio item number: OH250004 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 58064 +/-
Where
Aultman Hospital Canton, Ohio (NRC Region 3)
License number:	02120770003
Organization:	Ohio Bureau Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+34.37 h1.432 days <br />0.205 weeks <br />0.0471 months <br />)
Opened:	Michael Rubadue 15:22 Nov 26, 2025
NRC Officer:	Robert A. Thompson
Last Updated:	Nov 26, 2025
58064 - NRC Website
v • d • e

v t e Emergency Notification System
Aultman Hospital with Agreement State
WEEKMONTHYEAR2025-11-25T05:00:00 [Table view]
[ENS list for Aultman Hospital]

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