Event Notification Report for May 07, 2013
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
05/06/2013 - 05/07/2013
EVENT NUMBERS
49450
Agreement State
Event Number: 49450
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: ABINGTON MEMORIAL HOSPITAL
Region: 1
City: ABINGTON State: PA
County:
License #: PA-0055
Agreement: Y
Docket:
NRC Notified By: JOESEPH MELNIC
HQ OPS Officer: JOHN SHOEMAKER
Licensee: ABINGTON MEMORIAL HOSPITAL
Region: 1
City: ABINGTON State: PA
County:
License #: PA-0055
Agreement: Y
Docket:
NRC Notified By: JOESEPH MELNIC
HQ OPS Officer: JOHN SHOEMAKER
Notification Date: 10/18/2013
Notification Time: 15:28 [ET]
Event Date: 05/07/2013
Event Time: 00:00 [EDT]
Last Update Date: 10/18/2013
Notification Time: 15:28 [ET]
Event Date: 05/07/2013
Event Time: 00:00 [EDT]
Last Update Date: 10/18/2013
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
PAUL KROHN (R1DO)
FSME EVENTS RESOURCE (EMAI)
PAUL KROHN (R1DO)
FSME EVENTS RESOURCE (EMAI)
AGREEMENT STATE REPORT - MEDICAL EVENT INVOLVING THE ADMINISTRATION OF AN UNDER-DOSE TO A PATIENT
The following report was received via email:
"Event type: Medical Event involving the administration of yttrium-90 (Y-90) Sir-Spheres.
"Notifications: On October 17, 2013 the licensee informed the Department's Central Office of the Medical Event. The event is reportable within 24 hours per 10 CFR 35.3045(a)(1)(i). Appropriate reporting to the referring physician and the patient is currently underway.
"Event Description: The patient was scheduled to receive two split doses on May 7, 2013. The plan was to treat the left hepatic artery segment 2 and 3 with 11.9 mCi (0.44 GBq) and the left hepatic artery segment 4 with 11.9 mCi (0.44 GBq). The unit doses were assayed separately and were found to be within 10% of the prescribed doses. After the doses were assayed, the exposure rate around the jar was measured and documented. After the procedure was completed, the tubing, V-Vial, and the jar were collected and then measured to calculate the residual activity using the same procedure and geometry used during the pre-dose measurements as per procedure. The post treatment measurements and calculations revealed the following delivered doses. The left hepatic artery segment 2 and 3 branches received 9.2 mCi and the left hepatic artery segment 4 branch received 8.92 mCi. This resulted in under-dosing of 22.48% and 30.03% respectively.
"CAUSE OF THE EVENT: Occlusion of SirSpheres in the delivery system. The post treatment measurements were high which indicated that there were some spheres in the tubing or the V-Vial. When the jar was opened, it was found that the three-way stop cock contained some of the activity.
"ACTIONS: A new dose work sheet has been built in as a warning to remind the licensee to notify the regulatory agency should the dose variance exceed 20%.
"Media attention: None at this time."
Pennsylvania Event Report Number - PA130055
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 report was received via email:
"Event type: Medical Event involving the administration of yttrium-90 (Y-90) Sir-Spheres.
"Notifications: On October 17, 2013 the licensee informed the Department's Central Office of the Medical Event. The event is reportable within 24 hours per 10 CFR 35.3045(a)(1)(i). Appropriate reporting to the referring physician and the patient is currently underway.
"Event Description: The patient was scheduled to receive two split doses on May 7, 2013. The plan was to treat the left hepatic artery segment 2 and 3 with 11.9 mCi (0.44 GBq) and the left hepatic artery segment 4 with 11.9 mCi (0.44 GBq). The unit doses were assayed separately and were found to be within 10% of the prescribed doses. After the doses were assayed, the exposure rate around the jar was measured and documented. After the procedure was completed, the tubing, V-Vial, and the jar were collected and then measured to calculate the residual activity using the same procedure and geometry used during the pre-dose measurements as per procedure. The post treatment measurements and calculations revealed the following delivered doses. The left hepatic artery segment 2 and 3 branches received 9.2 mCi and the left hepatic artery segment 4 branch received 8.92 mCi. This resulted in under-dosing of 22.48% and 30.03% respectively.
"CAUSE OF THE EVENT: Occlusion of SirSpheres in the delivery system. The post treatment measurements were high which indicated that there were some spheres in the tubing or the V-Vial. When the jar was opened, it was found that the three-way stop cock contained some of the activity.
"ACTIONS: A new dose work sheet has been built in as a warning to remind the licensee to notify the regulatory agency should the dose variance exceed 20%.
"Media attention: None at this time."
Pennsylvania Event Report Number - PA130055
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.