ENS 52457

v t e ENS Event
05:00 Dec 20, 2016
Title	Agreement State Report - Medical Underdose
Event Description	The following report was received via fax: On December 20, 2016, a leak occurred during an administration of Yttrium-90 (Y-90) TheraSpheres to a patient, resulting in less than 80% of the prescribed dosage being administered. A total of about 8.99 millicurie of Y-90 activity was administered; or 34.6% of the prescribed 25.95 mCi activity. The prescribed dose was 17,470 rad (174.7 gray), with the leak resulting in a dose to the patient's liver of about 6,040 rad (60.4 Gy). The leak also caused contamination of the administration area, which was immediately and successfully decontaminated. As an under-dose, no immediate harmful effect to the patient resulted from the event. The referring physician and patient were made aware of the event during the procedure. Pennsylvania event: PA-160040 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.

ENS 52457 +/-
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:+55.77 h2.324 days <br />0.332 weeks <br />0.0764 months <br />)
Opened:	David Allard 12:46 Dec 22, 2016
NRC Officer:	Mark Abramovitz
Last Updated:	Dec 22, 2016
52457 - NRC Website
v • d • e

v t e Emergency Notification System
University Of Pennsylvania with Agreement State
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