ENS 53011

v t e ENS Event
15:05 Oct 12, 2017
Title	Agreement State Report - Dose Delivered Less than Prescribed
Event Description	The following information was received from the State of Ohio via email: On 10/12/17 during an infusion of Y-90 SIRSpheres that began at 11:05 a.m. [EDT], the treatment device malfunctioned and ceased delivery of the radioisotope, resulting in an under-dosing of the patient's liver. No contamination of the facilities or personnel was detected. All activity that was not delivered into the patient was placed back into the acrylic box and secured in the nuclear medicine hot lab for decay. A SIRSpheres representative was present during the treatment, but the cause of the malfunction is not known at this time. Once sufficient decay of the radioisotope has occurred, the delivery device will be shipped to SIRSpheres for technical analysis and root cause determination. The patient was informed on the day of the event. Ohio Item Number: OH170006 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 53011 +/-
Where
Adena Regional Medical Center Chillicothe, Ohio (NRC Region 3)
License number:	02120720000
Organization:	Ohio Bureau Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+22.67 h0.945 days <br />0.135 weeks <br />0.0311 months <br />)
Opened:	Michael J. Rubadue 13:45 Oct 13, 2017
NRC Officer:	Richard Smith
Last Updated:	Oct 13, 2017
53011 - NRC Website
v • d • e

v t e Emergency Notification System
Adena Regional Medical Center with Agreement State
WEEKMONTHYEAR2017-10-12T15:05:00 [Table view]
[ENS list for Adena Regional Medical Center]

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