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Event Notification Report for July 27, 2017

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
07/26/2017 - 07/27/2017

** EVENT NUMBERS **

Agreement State	Event Number: 52864
Rep Org: KANSAS DEPT OF HEALTH & ENVIRONMENT Licensee: UNIVERSITY OF KANSAS HOSPITAL AUTHORITY Region: 4 City: KANSAS CITY State: KS County: License #: 18-C801 Agreement: Y Docket: NRC Notified By: JAMES UHLEMEYER HQ OPS Officer: HOWIE CROUCH	Notification Date: 07/19/2017 Notification Time: 17:11 [ET] Event Date: 07/18/2017 Event Time: [CDT] Last Update Date: 07/19/2017
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): THOMAS HIPSCHMAN (R4DO) NMSS_EVENTS_NOTIFICA (EMAI)

Event Text

KANSAS AGREEMENT STATE REPORT - MEDICAL EVENT

The following information was received from the state of Kansas via email:

"A medical event occurred during a Yttrium-90 TheraSphere treatment of a patient's liver cancer. The patient received approximately 24 percent of the dose prescribed in the written directive. There was no harm to the patient other than the inconvenience of rescheduling the treatment to receive the remainder of the dose.

"[The licensee is] investigating the event and will submit a report within the required 15 days. With this procedure the vial containing the TheraSpheres cannot be viewed due to being inside a lead pig. Therefore, a digital radiation dosimeter is placed near the delivery device. As the dose is delivered to the patient, the readings drop to or near zero. In this case, the technologists and the physician stated the dosimeter was reading 0.0 at the end of the procedure.

"[The licensee's] immediate corrective action will be for radiation safety staff to verify the instrument readings when the physician feels the entire dose has been delivered."

The prescribed dose or quantity was not provided by the State.

Kansas NMED Item Number KS170006

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.

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