The following report was received from the State of
Utah via email:
Two patients were scheduled to receive TheraSphere infusions containing microspheres of Yttrium-90 on the same day [02/02/12]. Patient #1 was to receive 5.32 GBq for a treatment dose of 120 Gy. Patient #2 was to receive 1.77 GBq for a treatment dose of 120 Gy. Patient #1 received the dosage for Patient #2 (i.e., 1.77 GBq). The error was detected prior to Patient #2 receiving a dosage. The licensee determined that Patient #1 received a dose that was 33% lower than the prescribed dose in the written directive. The licensee determined this to be a medical event. However, the licensee did not provide enough information to determine if this event is or is not an Abnormal Occurrence. An on-site investigation is planned by the Utah Division of Radiation Control to occur within the next several days.
Utah Event Report ID Number: UT120001.
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.