ENS Event | |
|---|---|
06:00 Nov 21, 2022 | |
| Title | Underdose of YTTRIUM-90 SIR-SPHERES |
| Event Description | The following information was provided by the Texas Department of State Health Services (the Department) via email:
On November 23, 2022, the Department was notified by a licensee of a medical event involving Yttrium-90 Sir-Spheres. The procedure took place on November 21 and was thought to occur without incident, but when the tubing was measured on November 22, they found significant activity indicating that only 61.6 percent of the intended activity or material had been inserted into the patient. The intended activity to be inserted was 13.4 mCi and the actual activity delivered was 8.26 mCi. The room was surveyed after the procedure and no significant leakage or contamination was found. The patient and prescribing physician should be notified today. Further information will be supplied per SA-300. The investigation is ongoing. Texas Incident Number: 9965 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 | |
|---|---|
| Chi St Lukes Health Baylor Houston, Texas (NRC Region 4) | |
| License number: | L06661 |
| Organization: | Texas Dept Of State Health Services |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+53.5 h2.229 days <br />0.318 weeks <br />0.0733 months <br />) | |
| Opened: | Randall Redd 11:30 Nov 23, 2022 |
| NRC Officer: | Ernest West |
| Last Updated: | Nov 23, 2022 |
| 56237 - NRC Website | |
Chi St Lukes Health Baylor with Agreement State | |
WEEKMONTHYEARENS 562372022-11-21T06:00:00021 November 2022 06:00:00
[Table view]Agreement State Underdose of YTTRIUM-90 SIR-SPHERES 2022-11-21T06:00:00 | |