Event Notification Report for November 27, 2023

MEDICAL EVENT - Y-90 POTENTIAL UNDERDOSE

The following information was provided by the UP (Upper Peninsula) Health Systems Marquette via phone in accordance with Headquarters Operations Officers Report Guidance:

On 11/17/23 at 1100 EST at UP Health System Marquette, the radiation safety officer (RSO) determined that a patient received a dose that differed from the prescribed dose by more than 20 percent. The patient was prescribed a dose of 11.34 mCi of Y-90. The target organ was a tumor located in the patient's liver. The dose was administered to the target organ as expected, however, calculations on the remaining radioactivity left over from the administration estimated that the patient received a dose of only 2.82 mCi (24.9 percent of the prescribed dose). The RSO notified the referring physician, and the referring physician will notify the patient. The RSO is currently investigating the cause of the underdose and will submit a 15-day written report to follow up once the investigation is complete.

* * * RETRACTION ON 11/20/23 AT 1111 EST FROM BILL PYLE TO BILL GOTT * * *

The following information was provided by the UP (Upper Peninsula) Health Systems Marquette via phone:

The initial dose estimate was based on incorrect measurements and has been revaluated and the dose was in the acceptable range.

Notified R3DO (Feliz-Adorno) and NMSS Events Notification (via email).

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.