ENS Event | |
|---|---|
04:00 Jul 7, 2025 | |
| Title | Medical Event |
| Event Description | The following report was provided by the Georgia Radioactive Materials Program via email:
The licensee called and stated that during a post treatment review with the physician conducted today, it was identified that a patient receiving yttrium-90 therapy on July 7, 2025, was underexposed due to a kink in the catheter. The prescribed dose was 0.439 GBq (11.853 mCi), but the administered dose was determined to be 0.177 GBq (4.779 mCi). This represents a 40.32 percent deviation from the prescribed dose, which exceeds the 20 percent reporting threshold. Upon further review of the patient's treatment history, it was additionally discovered that two prior underdosing events occurred on August 20, 2024, and September 30, 2024. Both events were also attributed to catheter kinking and involved dose delivery to small treatment volumes in limited target areas. [The licensee] stated that a formal written report detailing all three underdosing events, along with supporting documentation, will be submitted via email on Monday, August 4, 2025. Georgia Incident Number: 105 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 | |
|---|---|
| Doctors Hospital Augusta, Georgia (NRC Region 1) | |
| License number: | GA 615-1 |
| Organization: | Georgia Radioactive Material Pgm |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+612.48 h25.52 days <br />3.646 weeks <br />0.839 months <br />) | |
| Opened: | Anastasia Bennett 16:29 Aug 1, 2025 |
| NRC Officer: | Jon Lilliendahl |
| Last Updated: | Aug 1, 2025 |
| 57845 - NRC Website | |
Doctors Hospital with Agreement State | |
WEEKMONTHYEARENS 578452025-07-07T04:00:0007 July 2025 04:00:00
[Table view]Agreement State Medical Event 2025-07-07T04:00:00 | |