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Start date | Reporting criterion | Title | Event description | System | LER | |
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ENS 56746 | 18 September 2023 16:00:00 | Agreement State | Underdose | The following information was received from the Colorado Department of Public Health and Environment via email: After completing a Yttrium-90 TheraSpheres treatment, (medical personnel) were measuring the residual Yttrium-90 TheraSpheres and found that the administered dose delivered to the patient was only 313.2 Gray and the prescribed dose was 407 Gray. The total dose delivered was only 77 percent of the prescribed dose. The department is investigating the cause of the event. Colorado Event Report ID: CO 230032 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. |