Event Notification Report for June 12, 2020
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
06/11/2020 - 06/12/2020
EVENT NUMBERS
54745
Agreement State
Event Number: 54745
Rep Org: ARIZONA DEPT OF HEALTH SERVICES
Licensee: Mayo Clinic Hospital
Region: 4
City: Phoenix State: AZ
County:
License #: 07-448
Agreement: Y
Docket:
NRC Notified By: Brian Goretzki
HQ OPS Officer: Jeffrey Whited
Licensee: Mayo Clinic Hospital
Region: 4
City: Phoenix State: AZ
County:
License #: 07-448
Agreement: Y
Docket:
NRC Notified By: Brian Goretzki
HQ OPS Officer: Jeffrey Whited
Notification Date: 06/13/2020
Notification Time: 20:08 [ET]
Event Date: 06/12/2020
Event Time: 00:00 [MST]
Last Update Date: 06/13/2020
Notification Time: 20:08 [ET]
Event Date: 06/12/2020
Event Time: 00:00 [MST]
Last Update Date: 06/13/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
JASON KOZAL (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
JASON KOZAL (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - MEDICAL EVENT
The following was received from the Arizona Department of Health Services (the Department) via email:
"On June 12, 2020, the Department received notification from the licensee of a possible medical event involving an I-125 eye plaque. A patient was implanted with an eye plaque on June 4, with a prescribed dose of 85 Gy. On June 8, the patient had a stroke and was admitted to St. Joseph's Medical Center. Once the patient was able to be transported, they were transported back to the Mayo Clinic Hospital on June 9. It was then determined that the patient was not strong enough to endure the procedure for removing the eye plaque. The eye plaque was finally removed on June 11 and the final dose to the tumor was 123.5 Gy or 145.3 percent of the prescription.
"The Department has requested additional information and continues to investigate the event."
Arizona Incident 20-010
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 Arizona Department of Health Services (the Department) via email:
"On June 12, 2020, the Department received notification from the licensee of a possible medical event involving an I-125 eye plaque. A patient was implanted with an eye plaque on June 4, with a prescribed dose of 85 Gy. On June 8, the patient had a stroke and was admitted to St. Joseph's Medical Center. Once the patient was able to be transported, they were transported back to the Mayo Clinic Hospital on June 9. It was then determined that the patient was not strong enough to endure the procedure for removing the eye plaque. The eye plaque was finally removed on June 11 and the final dose to the tumor was 123.5 Gy or 145.3 percent of the prescription.
"The Department has requested additional information and continues to investigate the event."
Arizona Incident 20-010
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.