Event Notification Report for February 07, 2025
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
02/06/2025 - 02/07/2025
EVENT NUMBERS
57538
57538
Agreement State
Event Number: 57538
Rep Org: Ohio Bureau of Radiation Protection
Licensee: Riverside Methodist Hospital
Region: 3
City: Columbus State: OH
County:
License #: 02120250070
Agreement: Y
Docket:
NRC Notified By: Michael Rubadue
HQ OPS Officer: Kerby Scales
Licensee: Riverside Methodist Hospital
Region: 3
City: Columbus State: OH
County:
License #: 02120250070
Agreement: Y
Docket:
NRC Notified By: Michael Rubadue
HQ OPS Officer: Kerby Scales
Notification Date: 02/10/2025
Notification Time: 10:30 [ET]
Event Date: 02/07/2025
Event Time: 00:00 [EST]
Last Update Date: 02/10/2025
Notification Time: 10:30 [ET]
Event Date: 02/07/2025
Event Time: 00:00 [EST]
Last Update Date: 02/10/2025
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Orlikowski, Robert (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Allen, Logan (NMSS )
Orlikowski, Robert (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Allen, Logan (NMSS )
AGREEMENT STATE REPORT - MEDICAL EVENT
The following information was received by the Ohio Department of Health via email:
"On February 7, 2025, the Ohio Department of Health was notified of a medical event involving Y-90 TheraSpheres. Two patients were scheduled to receive treatment on February 7, 2025, however, patient 'A' received the dose prescribed to patient 'B'. The written directive stated patient 'A' was to receive 160 Gy (47 mCi) but instead received 92 Gy (27 mCi), resulting in an underdose of 43 percent. The apparent cause was due to transposing the vial lot numbers when entering the information into the hospital's patient tracking system. The hospital caught the error before patient 'B' was treated, and patient 'B' received the dose prescribed in the written directive. Patient 'A' and his physician were notified. The patient will be evaluated to determine if additional treatment is required. An investigation of this event is pending."
Ohio Item Number: OH250002
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.
The following information was received by the Ohio Department of Health via email:
"On February 7, 2025, the Ohio Department of Health was notified of a medical event involving Y-90 TheraSpheres. Two patients were scheduled to receive treatment on February 7, 2025, however, patient 'A' received the dose prescribed to patient 'B'. The written directive stated patient 'A' was to receive 160 Gy (47 mCi) but instead received 92 Gy (27 mCi), resulting in an underdose of 43 percent. The apparent cause was due to transposing the vial lot numbers when entering the information into the hospital's patient tracking system. The hospital caught the error before patient 'B' was treated, and patient 'B' received the dose prescribed in the written directive. Patient 'A' and his physician were notified. The patient will be evaluated to determine if additional treatment is required. An investigation of this event is pending."
Ohio Item Number: OH250002
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.