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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 55354 | 14 July 2021 04:00:00 | Agreement State | Dose Administered Varied by More than 25 Percent | The following was received from the Ohio Department of Health via email: A patient whose thyroid had been removed was to receive treatment for the remaining nodules. The WD ((written directive)) prescribed 30 mCi I-131 NaI. However the licensee ordered and administered 100 mCi. The expected whole body dose is 26.64 rem and dose to the bladder wall is 225.7 rad. Item Number: OH210006 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 54181 | 27 June 2019 04:00:00 | Agreement State | Agreement State Report - Underdose to the Liver | The following information is summarized from an email received from the state of Ohio: A patient was undergoing Y-90 Therasphere treatment of both lobes of the liver. The calculations and dose were ordered for the volume of the left lobe which was 230cc. Due to a communication error, that dose was delivered to the right lobe which had a volume of 1600cc. This represents an underdose to the right lobe. The intended dose to the right lobe was 120 Gy. The delivered dose was 17.6 Gy. The licensee is evaluating additional treatment. The patient and prescribing physician were notified. The State will be performing an investigation. Ohio report no.: OH190013 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. |