ENS Event | |
|---|---|
04:00 Sep 22, 2025 | |
| Title | Medical Event |
| Event Description | The following is a summary of information received from the New York City Department of Health via email:
Memorial Sloan Kettering Cancer Center reported a Y-90 TheraSphere treatment to one site in the liver out of four resulting in 20.7 percent less dose than intended. The planned dose to the treatment site was 235 Gy; only 187 Gy was delivered. The treatment involved four vials to be used. Two of the vials were mistakenly switched during the treatment, resulting in the incorrect dose to one location. The patient was informed. New York item number: NY250006 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. |
| Where | |
|---|---|
| Memorial Sloan Kettering Cancer Center New York, New York (NRC Region 1) | |
| License number: | 75-2968-01 |
| Organization: | New York City Bureau Of Rad Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+751.75 h31.323 days <br />4.475 weeks <br />1.03 months <br />) | |
| Opened: | Erik Finkelstein 11:45 Oct 23, 2025 |
| NRC Officer: | Ian Howard |
| Last Updated: | Oct 23, 2025 |
| 58005 - NRC Website | |
Memorial Sloan Kettering Cancer Center with Agreement State | |
WEEKMONTHYEARENS 580052025-09-22T04:00:00022 September 2025 04:00:00
[Table view]Agreement State Medical Event ENS 573412024-09-24T04:00:00024 September 2024 04:00:00 Agreement State Medical Misadministration ENS 519922015-01-16T04:00:00016 January 2015 04:00:00 Agreement State Agreement State Report - Medical Underdose 2025-09-22T04:00:00 | |