ENS Event | |
|---|---|
23:00 Jun 18, 2007 | |
| Title | |
| Event Description | Written order was requested for a therapy dose of 2.45 GBq (66.2 milliCuries) of Y-90 TheraSphere for treatment to the patient's liver. 1.74 GBq (47 milliCuries) was received from MDS Nordion and used for treatment. Calculation error may have contributed to under treatment with approximately 80 Gray delivered to the liver with an intended dose of 100-110 Gray. Concern to not exceed lung dose of 15 Gray achieved with treatment dose at low end of optimal range. Physician notified and will consult with patient to decide whether to conduct additional treatment.
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 | |
|---|---|
| Oregon Health Science University Portland, Oregon (NRC Region 4) | |
| License number: | Ore-90013 |
| Organization: | Or Dept Of Health Rad Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+43.9 h1.829 days <br />0.261 weeks <br />0.0601 months <br />) | |
| Opened: | Terry Lindsey 18:54 Jun 20, 2007 |
| NRC Officer: | Jeff Rotton |
| Last Updated: | Jun 20, 2007 |
| 43434 - NRC Website | |
Oregon Health Science University with Agreement State | |
WEEKMONTHYEARENS 434342007-06-18T23:00:00018 June 2007 23:00:00
[Table view]Agreement State Oregon Agreement State Report - Potential Underdose Treatment to Liver 2007-06-18T23:00:00 | |