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 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 | |
|---|---|
| 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 | |
University Of Texas with Agreement State | |
WEEKMONTHYEARENS 580282025-09-11T06:00:00011 September 2025 06:00:00
[Table view]Agreement State Medical Event ENS 501032014-05-08T05:00:0008 May 2014 05:00:00 Agreement State Agreement State Report Involving Over Dose to Patient ENS 454512009-10-21T05:00:00021 October 2009 05:00:00 Agreement State Agreement State Report - Removable Contamination on a Package 2025-09-11T06:00:00 | |