ENS 47763
ENS Event | |
|---|---|
04:00 Mar 20, 2012 | |
| Title | Agreement State Report - Underdose During Liver Disease Treatment |
| Event Description | Event type: A medical event (ME) involving the administration of Yittrium-90 SIR-Spheres which is reportable under 10 CFR 35.3045(a)(1)(i).
Notifications: On March 21,2012, the Department's [Pennsylvania Department of Environmental Protection, Bureau of Radiation Protection] Southeast Regional Office received notification via a phone call about this ME. Event Description: The patient was being treated for disease of the liver and received 77% of the intended dose. CAUSE OF THE EVENT: Currently under investigation and unknown at this time. ACTIONS: No harm to the patient is expected. The treating physician notified the patient. The Department [Pennsylvania Department of Environmental Protection, Bureau of Radiation Protection] plans to do a reactive inspection. PA Event Report ID: PA120009. 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.
Notifications: On March 21, 2012, the Department's Southeast Regional Office received notification via a phone call about this ME. After the HOO notification was made the Department was informed that the measurement for actual dose delivered was repeated two times, both indicating the administration was within acceptable limits. Event Description: The patient was being treated for disease of the liver and was initially thought to have received 77% of the intended dose, however after additional measurements were made the dosage delivered was determined to be 81.2% and 82.2%. ACTIONS: Medical Event is being retracted. Notified the R1DO (Newport) and FSME EO (McIntosh). |
| Where | |
|---|---|
| University Of Pennsylvania Philadelphia, Pennsylvania (NRC Region 1) | |
| License number: | Pa-0131 |
| Organization: | Pa Bureau Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+64.43 h2.685 days <br />0.384 weeks <br />0.0883 months <br />) | |
| Opened: | David J. Allard 20:26 Mar 22, 2012 |
| NRC Officer: | Pete Snyder |
| Last Updated: | Mar 26, 2012 |
| 47763 - NRC Website
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University of Pennsylvania with Agreement State | |
WEEKMONTHYEARENS 570812024-04-17T04:00:00017 April 2024 04:00:00
[Table view]Agreement State Medical Underdose ENS 566612023-08-05T15:07:0005 August 2023 15:07:00 Agreement State Medical Underdose ENS 570862023-01-31T04:00:00031 January 2023 04:00:00 Agreement State Medical Event ENS 570852022-12-29T04:00:00029 December 2022 04:00:00 Agreement State Medical Event ENS 570842022-12-28T04:00:00028 December 2022 04:00:00 Agreement State Medical Event ENS 558892022-05-04T04:00:0004 May 2022 04:00:00 Agreement State Underdose ENS 558512022-04-18T04:00:00018 April 2022 04:00:00 Agreement State Patient Underdose ENS 553372021-07-02T04:00:0002 July 2021 04:00:00 Agreement State Patient Under Dose ENS 549642020-10-20T04:00:00020 October 2020 04:00:00 Agreement State Missing Licensed Material ENS 534302018-05-25T04:00:00025 May 2018 04:00:00 Agreement State En Revision Imported Date 10/15/2018 ENS 525042017-01-19T05:00:00019 January 2017 05:00:00 Agreement State Agreement State Report - Received Dose Less than Prescribed Dose ENS 524572016-12-20T05:00:00020 December 2016 05:00:00 Agreement State Agreement State Report - Medical Underdose ENS 483032012-09-11T04:00:00011 September 2012 04:00:00 Agreement State Agreement State Report - Patient Underexposure Using Yttrium-90 Sir-Spheres Treatment ENS 482292012-08-23T04:00:00023 August 2012 04:00:00 Agreement State Agreement State Report - Patient Underexposure Using Yttrium-90 Sir-Spheres Treatment ENS 481372012-07-26T04:00:00026 July 2012 04:00:00 Agreement State Agreement State Report - Medical Event Involving an Underdose with Yttrium-90 Spheres ENS 477632012-03-20T04:00:00020 March 2012 04:00:00 Agreement State Agreement State Report - Underdose During Liver Disease Treatment ENS 474352011-11-10T12:00:00010 November 2011 12:00:00 Agreement State Agreement State Report - Underdosage of Theraspheres ENS 461012010-07-07T04:00:0007 July 2010 04:00:00 Agreement State Agreement State Report - Delivered Dose Differed from the Prescribed Dose by Greater than 50% ENS 457272010-01-21T05:00:00021 January 2010 05:00:00 Agreement State Agreement State Report - Brachytherapy Implants Outside of the Intended Treatment Area 2024-04-17T04:00:00 | |