ENS Event | |
|---|---|
05:00 Mar 5, 2014 | |
| Title | Agreement State Report - Under Dose Involving Yttrium 90 Microspheres |
| Event Description | The following information was received by email:
On March 6, 2014, UMass Memorial Health Care (license number 60-0096) reported [to the Massachusetts Radiation Control Program] that on March 5, 2014 they had under dosed a patient by more than 20% using Y-90 microspheres. Further pertinent data is: Prescribed Activity: 26.4 mCi of Y-90 (in one fraction injection) Delivered Activity: 20.4 mCi of Y-90 (more than 20% different from prescribed) Resulting in: Prescribed Liver dose: = 32.6 Gy Delivered Liver dose: = 25.2 Gy Dose difference in organ: = 740 rads (i.e., greater than 50 rem and 20% difference) Note Also: Effective dose (requested): 32.6 Gy * 0.04 = 1.3 Sv Effective dose (delivered): 25.2 Gy * 0.04 = 1.0 Sv Effective dose difference: 1.3-1.0=0.3 Sv = 30 rem (greater than 5 rem difference) 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 | |
|---|---|
| Umass Memorial Health Care Worcester, Massachusetts (NRC Region 1) | |
| License number: | 60-0096 |
| Organization: | Ma Radiation Control Program |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+51.45 h2.144 days <br />0.306 weeks <br />0.0705 months <br />) | |
| Opened: | Michael Whalen 08:27 Mar 7, 2014 |
| NRC Officer: | Dong Park |
| Last Updated: | Mar 7, 2014 |
| 49881 - NRC Website | |
Umass Memorial Health Care with Agreement State | |
WEEKMONTHYEARENS 539712019-04-02T14:42:0002 April 2019 14:42:00
[Table view]Agreement State Agreement State Report - Medical Event - Underdose Administration of Y-90 Microspheres ENS 498812014-03-05T05:00:0005 March 2014 05:00:00 Agreement State Agreement State Report - Under Dose Involving Yttrium 90 Microspheres ENS 455422009-09-11T05:00:00011 September 2009 05:00:00 Agreement State Agreement State Report- Potential Loss of Radioactive Material 2019-04-02T14:42:00 | |