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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 53877 | 13 February 2019 05:00:00 | Agreement State | Agreement State Report - Administered Dose to Unintended Organs Results or Will Result in Unintended Permanent Damage | The following was received from the Pennsylvania Department of Environmental Protection (DEP) Bureau of Radiation Protection via email: On February 13, 2019, the patient was prescribed 31.3 milliCuries (mCi) Yttrium-90 (Y-90) Sirsphere for metastatic colorectal cancer and 31.69 mCi was delivered at time of treatment. From the post Y-90 Bremsstrahlung scan, performed on the day of treatment, it was discovered by the nuclear medicine physician, that some of the Y-90 microspheres also traveled to the stomach and left lobe of liver. The doctor has informed the patient and the patient is being monitored for potential complications. The doctor is working to determine the percentage of the Y-90 that went to stomach and left lobe of liver. No more information is available at this time from the licensee. The DEP will update this event as soon as more information is provided. The DEP will perform a reactive inspection. The licensee reported this to the state per 10 CFR 35.3045 (b). Pennsylvania Report: PA190004 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. |