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Event Notification Report for February 28, 2020

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
2/27/2020 - 2/28/2020

** EVENT NUMBERS **

Agreement State	Event Number: 54534
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES Licensee: THE UNIVERSITY OF TEXAS HEALTH SCIENCE CENTER AT SAN ANTONIO Region: 4 City: SAN ANTONIO State: TX County: License #: L01279 Agreement: Y Docket: NRC Notified By: RANDALL REDD HQ OPS Officer: BRIAN P. SMITH	Notification Date: 02/20/2020 Notification Time: 17:50 [ET] Event Date: 02/19/2020 Event Time: 00:00 [CST] Last Update Date: 02/20/2020
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): GREG WERNER (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - UNDERDOSE OF YTTRIUM-90 DURING TREATMENT

"On February 20, 2020, the Radiation Safety Officer for the Licensee notified this Agency of a medical event involving yttrium-90 Theraspheres. The prescribed dose was 120 Gy but only 85.2 Gy was administered with the remaining intended dose left in the tubing. The remainder could not be flushed out and the procedure was halted. The Licensee will meet with the manufacturer next week at the Licensee's facility to address this issue. This investigation is ongoing. More information will be provided when obtained in accordance with SA-300."

Texas Incident Number: I-9745

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.

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