Event Notification Report for December 15, 2018
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
12/14/2018 - 12/15/2018
EVENT NUMBERS
53794
Agreement State
Event Number: 53794
Rep Org: COLORADO DEPT OF HEALTH
Licensee: SWEDISH MEDICAL CENTER
Region: 4
City: ENGLEWOOD State: CO
County:
License #: CO 251-02
Agreement: Y
Docket:
NRC Notified By: DEREK BAILEY
HQ OPS Officer: JOANNA BRIDGE
Licensee: SWEDISH MEDICAL CENTER
Region: 4
City: ENGLEWOOD State: CO
County:
License #: CO 251-02
Agreement: Y
Docket:
NRC Notified By: DEREK BAILEY
HQ OPS Officer: JOANNA BRIDGE
Notification Date: 12/19/2018
Notification Time: 11:10 [ET]
Event Date: 12/15/2018
Event Time: 00:00 [MST]
Last Update Date: 12/19/2018
Notification Time: 11:10 [ET]
Event Date: 12/15/2018
Event Time: 00:00 [MST]
Last Update Date: 12/19/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
RYAN ALEXANDER (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
RYAN ALEXANDER (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION
The following was received from the State of Colorado via email:
"[Colorado Department of Public Health and Environment] CDPHE became aware of a misadministration on the evening of December 18th, 2018; the event was discovered by the licensee on the morning of December 18th, 2018. The event occurred over three consecutive days, December 15th, 16th, and 17th, 2018.
"Description of the events: The licensee reported that strontium break through occurred on a Braco (Rb-82) generator resulting in levels of Sr-82/Sr-85 exceeding manufacture specified limits. The licensee failed to identify the strontium breakthrough and the doses were subsequently used in patient procedures, eight (8) patients were affected.
"The licensee has no more information at this time and has been instructed to notify the department as soon as patient dose information becomes available. CDPHE is awaiting a full report by the licensee."
Colorado Event Report ID No.: CO180032
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 was received from the State of Colorado via email:
"[Colorado Department of Public Health and Environment] CDPHE became aware of a misadministration on the evening of December 18th, 2018; the event was discovered by the licensee on the morning of December 18th, 2018. The event occurred over three consecutive days, December 15th, 16th, and 17th, 2018.
"Description of the events: The licensee reported that strontium break through occurred on a Braco (Rb-82) generator resulting in levels of Sr-82/Sr-85 exceeding manufacture specified limits. The licensee failed to identify the strontium breakthrough and the doses were subsequently used in patient procedures, eight (8) patients were affected.
"The licensee has no more information at this time and has been instructed to notify the department as soon as patient dose information becomes available. CDPHE is awaiting a full report by the licensee."
Colorado Event Report ID No.: CO180032
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.