ENS 54230

v t e ENS Event
04:00 Aug 16, 2019
Title	Agreement State Report - Patient Under-Dosage
Event Description	The following was received via fax: On August 16, 2019, a patient underwent a Y-90 SIR-Sphere treatment. The treatment plan was for 2 administrations of Y-90. The first administration was delivered without incident. The second administration was to be a total dosage of 12.27 mCi delivered to the right lobe of the liver. During this second administration, it was observed that the team had backflow into the administration vile. The administration was immediately halted, and the team took readings to ascertain the amount of material delivered. It was estimated that only 28 percent of the dose was delivered to the patient. The patient was verbally informed the day of the event. The referring physician was left a voicemail on the day of the event, however further attempts will be made to contact him directly. Event Report ID No.: PA190019 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 54230 +/-
Where
Thomas Jefferson University Hospitals Philadelphia, Pennsylvania (NRC Region 1)
License number:	PA-0130
Organization:	Pa Bureau Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+82.28 h3.428 days <br />0.49 weeks <br />0.113 months <br />)
Opened:	John Chippo 14:17 Aug 19, 2019
NRC Officer:	Jeffrey Whited
Last Updated:	Aug 19, 2019
54230 - NRC Website
v • d • e

v t e Emergency Notification System
Thomas Jefferson University Hospitals with Agreement State
WEEKMONTHYEAR2019-08-16T04:00:00 [Table view]
[ENS list for Thomas Jefferson University Hospitals]

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