Event Notification Report for November 22, 2019
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
11/21/2019 - 11/22/2019
EVENT NUMBERS
54442
Agreement State
Event Number: 54442
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: UNIVERSITY OF MIAMI
Region: 1
City: MIAMI State: FL
County:
License #: 1319-1
Agreement: Y
Docket:
NRC Notified By: MATTHEW SENISON
HQ OPS Officer: THOMAS KENDZIA
Licensee: UNIVERSITY OF MIAMI
Region: 1
City: MIAMI State: FL
County:
License #: 1319-1
Agreement: Y
Docket:
NRC Notified By: MATTHEW SENISON
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 12/13/2019
Notification Time: 14:39 [ET]
Event Date: 11/22/2019
Event Time: 00:00 [EST]
Last Update Date: 12/13/2019
Notification Time: 14:39 [ET]
Event Date: 11/22/2019
Event Time: 00:00 [EST]
Last Update Date: 12/13/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTOPHER LALLY (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
CHRISTOPHER LALLY (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - EQUIPMENT FAILURE DURING MEDICAL TREATMENT
The following was received from the Florida Bureau of Radiation Control (the Bureau) via email:
"At [licensee], on or around 1745 EST 22 November 2019, a male patient being treated with Y-90 theraspheres had a blockage on the catheter. The Interventional Radiologist increased the pressure on the line, rupturing the intubation tube. No contamination of staff, only patient. Decontamination of the room and patient followed, no contamination on skin, only gown and tube. Vials were disposed of with waste, so no batch numbers of spheres are available at this time. Problems with imaging occurred, so there are no images at this time. The Radiation Safety Officer (RSO) has asked for reports with more information from Interventional Radiologist (IR) and Radiation Oncologist Authorized User (ROAU). IR and ROAU disagree on how much activity the patient received before the rupture; patient was prescribed 15 mCi. Patient will return for further treatment. The Bureau has been notified and an inspector will be assigned to investigate."
Incident Number: FL19-141
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 Florida Bureau of Radiation Control (the Bureau) via email:
"At [licensee], on or around 1745 EST 22 November 2019, a male patient being treated with Y-90 theraspheres had a blockage on the catheter. The Interventional Radiologist increased the pressure on the line, rupturing the intubation tube. No contamination of staff, only patient. Decontamination of the room and patient followed, no contamination on skin, only gown and tube. Vials were disposed of with waste, so no batch numbers of spheres are available at this time. Problems with imaging occurred, so there are no images at this time. The Radiation Safety Officer (RSO) has asked for reports with more information from Interventional Radiologist (IR) and Radiation Oncologist Authorized User (ROAU). IR and ROAU disagree on how much activity the patient received before the rupture; patient was prescribed 15 mCi. Patient will return for further treatment. The Bureau has been notified and an inspector will be assigned to investigate."
Incident Number: FL19-141
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.