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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 55329 | 25 June 2021 16:00:00 | Agreement State | Underdose to Patient | The following report was received from the Wisconsin Radiation Protection Section (the State): On June 25, 2021, the licensee reported to the State a misadministration of Y-90 Theraspheres on the morning of the same day. The prescribed dose was 126 Gy to the right lobe of the liver, corresponding to 2.31 GBq. After the administration was complete, the licensee surveyed the residual material and noticed that an unusually high amount of material was still present in the administration setup. Initial calculations indicate that approximately 1.572 GBq of material was delivered to the patient. This corresponds to 68.8 percent of the prescribed dose resulting in a dose to the right lobe of the liver that differed from the prescribed dose by 39.2 Gy. The technologist notified the Authorized User immediately and the Authorized User then notified the patient. No unusual circumstances or events were noted during the administration, and there are no suspected spills or outside exposures resulting from this event. The State will continue to follow up on the event. Wisconsin Event Report: WI210005 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. |