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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 54151 | 5 July 2019 04:00:00 | Agreement State | Agreement State Report - Patient Underdose | The follow was received via fax: On July 8, 2019, the Department (Pennsylvania Department, Bureau of Radiation Protection) became aware of an under-dose event involving yttrium-90 (Y-90) SIR-Spheres. It is reportable as per 10 CFR 35.3045(a)(1)(i). On July 5, 2019, a patient underwent a Y-90 SIR-Sphere treatment. The total dosage of 9.58 mCi was split into two equal dosages of 4.79 mCi to be administered to segments 5 and 8 of the liver. The first vial, segment 5, was successfully administered but only 75.7 percent or 3.6 mCi of the second vial was administered to segment 8. The referring physician and the patient were verbally informed. No harm is expected to the patient. The Department will perform a reactive inspection. Event Report ID No.: PA190015 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. |