Event Notification Report for April 16, 2020
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
04/15/2020 - 04/16/2020
EVENT NUMBERS
54672
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
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
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
10 CFR Section:
35.3045(a)(1) - Dose <> Prescribed Dosage
Person (Organization):
DONNA JANDA (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
DONNA JANDA (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
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.
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.