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Start date | Reporting criterion | Title | Event description | System | LER | |
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ENS 51287 | 30 July 2015 17:00:00 | 10 CFR 35.3045(a)(1) | Medical Event Resulting from Actual Treatment Dose 30 Percent Greater than Prescribed | On 7/31/2015, a patient was undergoing a single treatment for liver cancer using Y-90 microspheres (SIR-Spheres) with a prescribed dose from the physicians written directive of 29.43 milliCi. On 8/4/2015, it was discovered that the patient actually received 38.2 milliCi dose due a calculation error based on the physician's initial written directive when the physician had decided on a final dose reduction prior to treatment. The physician has been notified and believes that there will be no adverse effects to the patient. The patient will be notified on 8/5/2015. 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. |