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On 6/14/17 a patient undergoing treatment using Sir-Spheres (Y-90) received a dose of 540 Gray instead of the 110 Gray prescribed. This occurred due to a calibration error. The prescribing physician discussed the error with the patient who was released and returned home. The Radiation Safety Officer (RSO) is investigating the incident. No adverse effect to the patient has been observed to date.

• * * UPDATE PROVIDED BY YONGLI NING TO JEFF ROTTON AT 1816 EDT ON 06/28/2017 * * *

The original report is being updated to reflect that the dose information provided initially was for the liver (prescribed organ). Thera-Spheres were used in the procedure versus the Sir-Spheres as stated in the original report. The licensee also provided received dose information for the lung of 25.76 Gray from the event described above. Notified the R4DO (Kellar) and NMSS Events Notification group via email. 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.