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Event Notification Report for April 28, 2020

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
4/27/2020 - 4/28/2020

** EVENT NUMBERS **

Non-Agreement State	Event Number: 54672
Rep Org: CHRISTIANA CARE HEALTH SERVICES Licensee: CHRISTIANA CARE HEALTH SERVICES Region: 1 City: WILMINGTON State: DE County: License #: 07-12153-02 Agreement: N Docket: NRC Notified By: KAROL WEN HQ OPS Officer: CATY NOLAN	Notification Date: 04/17/2020 Notification Time: 12:37 [ET] Event Date: 04/16/2020 Event Time: 00:00 [EDT] Last Update Date: 04/17/2020
Emergency Class: NON EMERGENCY 10 CFR Section: 35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE	Person (Organization): DONNA JANDA (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

UNDERDOSE TO PATIENT

The following is a summary of information received via telephone:

On April 16, 2020, a patient received 11.5 percent of the prescribed dose of Y-90 TheraSphere therapy to the left liver. It is believed that the delivery device malfunctioned as the technician experienced increased pressure in the line when pushing the TheraSphere into the caster. The therapy was aborted after a few failed attempts. The intended dose was 97.3 milliCuries of Y-90. The patient is aware and will be returning for the remainder of the dose. The licensee contacted the vendor who will discard the malfunctioned device.

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.

Agreement State	Event Number: 54673
Rep Org: ARIZONA DEPT OF HEALTH SERVICES Licensee: SAINT JOSEPH'S HOSPITAL AND MEDICAL CENTER Region: 4 City: PHOENIX State: AZ County: License #: 07-024 Agreement: Y Docket: NRC Notified By: BRIAN GORETZKI HQ OPS Officer: BRIAN LIN	Notification Date: 04/18/2020 Notification Time: 12:20 [ET] Event Date: 04/17/2020 Event Time: 18:00 [MST] Last Update Date: 04/18/2020
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): JEFFREY JOSEY (R4DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - POSSIBLE MEDICAL EVENT

The following was received from the state of Arizona via email:

"On April 17, 2020, at approximately 1800 [MDT], the Department [Arizona Department of Health Services] received notification from the licensee of a possible medical event involving Yttrium-90 radiolabeled glass microspheres (Therasphere). The dose on the written directive was 150 Gy and the pre-treatment measurement was approximately 4.6 GBq. Following the delivery, the nuclear medicine technologist took readings of the waste containers and got an average of 4.58 mR/hr (highest of 11.8 mR/hr) from the first jar and an average of 1.39 mR/hr (highest of 2.6 mR/hr) from the second jar. The licensee is investigating the irregular waste readings and attempting to calculate the actual dose to the patient.

"The Department has requested additional information and continues to investigate the event."

Arizona Event No. 20-009

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.

Page Last Reviewed/Updated Thursday, March 25, 2021