ENS Event | |
|---|---|
05:00 Mar 12, 2021 | |
| Title | Dose Received Was Less than Prescribed Dose |
| Event Description | The following was received via an email from the state of Pennsylvania:
The Department [PA Bureau of Radiation Protection] received notification from a licensee on March 12, 2021 of medical event involving yttrium-90 TheraSphere [TM]. The licensee believes a patient received only 2 milliCurie of the 63.7 milliCurie prescribed dose. The connection piece between the Therasphere [TM] apparatus and the patient catheter failed when the injection started. All contamination was contained with absorbent pads that were located below the connection. The room, staff and patient were extensively surveyed and not found to be contaminated. The patient and the prescribing physician have been informed. No adverse effects to the patient are anticipated. The Department is currently in contact with the licensee and will update this event as soon as more information is provided. Pennsylvania Event Report ID No: PA210002 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 Pittsburgh Pittsburgh, Pennsylvania (NRC Region 1) | |
| License number: | PA-0190 |
| Organization: | Pa Bureau Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+78.8 h3.283 days <br />0.469 weeks <br />0.108 months <br />) | |
| Opened: | John Chippo 10:48 Mar 15, 2021 |
| NRC Officer: | Lloyd Desotell |
| Last Updated: | Mar 15, 2021 |
| 55139 - NRC Website | |
University Of Pittsburgh with Agreement State | |
WEEKMONTHYEARENS 567702023-09-28T04:00:00028 September 2023 04:00:00
[Table view]Agreement State Agreement State - I-125 Seed Inadvertently Transected ENS 551392021-03-12T05:00:00012 March 2021 05:00:00 Agreement State Dose Received Was Less than Prescribed Dose ENS 515672015-11-20T05:00:00020 November 2015 05:00:00 Agreement State Agreement State Report - Lost Radioactive Seed ENS 482862012-09-06T04:00:0006 September 2012 04:00:00 Agreement State Agreement State Report - Yttrium-90 Microspheres Administered to the Wrong Treatment Site 2023-09-28T04:00:00 | |