ENS 54672: Difference between revisions
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{{ENS notification | {{ENS notification | ||
| event number = 54672 | | event number = 54672 | ||
| facility = | | facility = | ||
| Organization = Christiana Care Health Services | | Organization = Christiana Care Health Services | ||
| license number = 07-12153-02 | | license number = 07-12153-02 | ||
| Line 10: | Line 10: | ||
| utype = | | utype = | ||
| cfr = 10 CFR 35.3045(a)(1) | | cfr = 10 CFR 35.3045(a)(1) | ||
| emergency class = | | emergency class = Non Emergency | ||
| notification date = 04/17/2020 12:37 | | notification date = 04/17/2020 12:37 | ||
| notification by = Karol Wen | | notification by = Karol Wen | ||
| Line 18: | Line 18: | ||
| title = Underdose to Patient | | title = Underdose to Patient | ||
| event text = The following is a summary of information received via telephone: | | event text = The following is a summary of information received via telephone: | ||
On April 16, 2020, a patient received 11.5 percent of the prescribed dose of Y-90 TheraSphere therapy to the left liver. | On April 16, 2020, a patient received 11.5 percent of the prescribed dose of Y-90 TheraSphere therapy to the left liver. It is believed that the delivery device malfunctioned as the technician experienced increased pressure in the line when pushing the TheraSphere into the caster. The therapy was aborted after a few failed attempts. The intended dose was 97.3 milliCuries of Y-90. The patient is aware and will be returning for the remainder of the dose. The licensee contacted the vendor who will discard the malfunctioned device. | ||
A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. | 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. | ||
| URL = https://www.nrc.gov/reading-rm/doc-collections/event-status/event/2020/20200428en.html#en54672 | | URL = https://www.nrc.gov/reading-rm/doc-collections/event-status/event/2020/20200428en.html#en54672 | ||
}} | }} | ||
{{ENS-Nav}} | {{ENS-Nav}} | ||
Latest revision as of 12:40, 15 January 2021
| Where | |
|---|---|
| Christiana Care Health Services Wilmington, Delaware (NRC Region 1) | |
| License number: | 07-12153-02 |
| Organization: | Christiana Care Health Services |
| Reporting | |
| 10 CFR 35.3045(a)(1) | |
| Time - Person (Reporting Time:+32.62 h1.359 days <br />0.194 weeks <br />0.0447 months <br />) | |
| Opened: | Karol Wen 12:37 Apr 17, 2020 |
| NRC Officer: | Caty Nolan |
| Last Updated: | Apr 17, 2020 |
| 54672 - NRC Website | |