ENS Event | |
|---|---|
18:45 Feb 13, 2020 | |
| Title | Agreement State Report - Underdose of Yttrium-90 During Treatment |
| Event Description | A medical event was reported to the Massachusetts Radiation Control Program on Friday, February 14, 2020. A patient receiving a therapeutic radiation dose to the right lobe of the liver using Y-90 Theraspheres in 2 fractionated doses was intended to receive 135 Grays for each fraction. The patient was administered 45.5 Grays for the first fraction and 129.4 Grays for the second. The first fraction underdosed the right lobe of the liver by greater than 50 percent and differed from the prescribed dose by greater than 0.5 Sv (50 rem) effective dose equivalent. The actual underdose for the first fraction was 8,950 rads. This exceeds the reporting limits of 10 CFR 35.3045(a)(1)(i)(c), 'Report and Notification of a Medical Event,' and 105 CMR 120.594(A)(1)(a)(3).
The licensee is investigating the cause of the event and will be reporting the results to the Massachusetts Radiation Control Program. |
| Where | |
|---|---|
| Massachusetts General Hospital Boston, Massachusetts (NRC Region 1) | |
| License number: | 60-0055 |
| Organization: | Ma Radiation Control Program |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+21.27 h0.886 days <br />0.127 weeks <br />0.0291 months <br />) | |
| Opened: | Kenath Traegde 16:01 Feb 14, 2020 |
| NRC Officer: | Howie Crouch |
| Last Updated: | Feb 14, 2020 |
| 54526 - NRC Website | |
Ma Radiation Control Program with Agreement State | ||
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