ENS 58028: Difference between revisions

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Revision as of 07:20, 13 November 2025

v t e ENS Event
06:00 Sep 11, 2025
Title	Medical Event
Event Description	The following information was provided by the Texas Department of State Health Services (the Department) via email: On November 6, 2025, the Department received a report from the licensee's radiation safety officer (RSO) stating that they had discovered three under exposure events had occurred using Y-90 TheraSphere beads. The events were discovered during a review of these procedures conducted by a new manager. The events occurred on September 11, [September] 18, and [September] 22, 2025. In the September 11 event, the patient was prescribed to receive 34.3 millicuries (mCi) but only received 20.0 mCi. In the September 18 event, the patient was prescribed two separate procedures of 34.3 and 48.9 mCi, but received 23.6 and 31.8 mCi [respectively]. In the September 22 event, the patient was prescribed 35.7 mCi but received 26.4 mCi. The final dose calculations were based on the recorded radiation readings taken on the delivery devices after the procedures. The RSO stated they have reviewed the records for the events and interviewed the individual who had taken the after-procedure radiation readings and was not able to determine the cause of the underexposures. The prescribing physicians in each case have been notified of the error. The patients will be notified by their physician of the events. The RSO stated they are continuing to investigate the cause of the under exposures. The RSO stated they do not expect any adverse effects on the patients. Additional information will be provided as it is received in accordance with SA-300. Texas Incident #: 10242 Texas NMED # TX250058 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 58028 +/-
Where
University Of Texas Dallas, Texas (NRC Region 4)
License number:	L00384
Organization:	Texas Dept Of State Health Services
Reporting

Agreement State
Time - Person (Reporting Time:+1353.42 h56.393 days <br />8.056 weeks <br />1.854 months <br />)
Opened:	Art Tucker 16:25 Nov 6, 2025
NRC Officer:	Ernest West
Last Updated:	Nov 6, 2025
58028 - NRC Website
v • d • e

v t e Emergency Notification System
University Of Texas with Agreement State
WEEKMONTHYEAR2025-09-11T06:00:00 [Table view]
[ENS list for University Of Texas]

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