Event Notification Report for May 08, 2019
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
05/07/2019 - 05/08/2019
EVENT NUMBERS
54057
Non-Agreement State
Event Number: 54057
Rep Org: QUEENS MEDICAL CENTER
Licensee: QUEENS MEDICAL CENTER
Region: 4
City: HONOLULU State: HI
County:
License #: 53-16533-02
Agreement: N
Docket:
NRC Notified By: DALE SCHIPPERS
HQ OPS Officer: THOMAS KENDZIA
Licensee: QUEENS MEDICAL CENTER
Region: 4
City: HONOLULU State: HI
County:
License #: 53-16533-02
Agreement: N
Docket:
NRC Notified By: DALE SCHIPPERS
HQ OPS Officer: THOMAS KENDZIA
Notification Date: 05/09/2019
Notification Time: 18:08 [ET]
Event Date: 05/08/2019
Event Time: 13:17 [HST]
Last Update Date: 05/09/2019
Notification Time: 18:08 [ET]
Event Date: 05/08/2019
Event Time: 13:17 [HST]
Last Update Date: 05/09/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(2) - DOSE > SPECIFIED EFF LIMITS
10 CFR Section:
35.3045(a)(2) - DOSE > SPECIFIED EFF LIMITS
Person (Organization):
RYAN ALEXANDER (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
RYAN ALEXANDER (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
ADMINISTRATION OF LESS THAN PRESCRIBED DOSE
"This was a Y-90 TheraSphere administration [120 Gy to the right lobe of the liver]. The catheter was guided to the right hepatic artery and the position was verified by fluoroscopy. No issues with catheter flow while administering contrast and normal saline. The catheter was connected to the primed infusion system and the dose delivery was initiated. The IR (Interventional Radiology) physician, under the supervision of the Authorized User, was delivering the dose. The IR physician saw several small air bubbles in the delivery line and then experienced high resistance. Some of the Y-90 activity (approximately 13.2 mCi or 0.49 GBq) was delivered to the patient. Approximately 60% of the activity was in the administration set and catheter. No contamination of the IR suite or of any of the personnel occurred. All of the dose was either in the delivery system/catheter or the patient.
"No harm was done to the patient since the activity was delivered to the target organ and the dose did not exceed the prescribed dose.
"The referring physician and the patient were notified within 24 hours."
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.
"This was a Y-90 TheraSphere administration [120 Gy to the right lobe of the liver]. The catheter was guided to the right hepatic artery and the position was verified by fluoroscopy. No issues with catheter flow while administering contrast and normal saline. The catheter was connected to the primed infusion system and the dose delivery was initiated. The IR (Interventional Radiology) physician, under the supervision of the Authorized User, was delivering the dose. The IR physician saw several small air bubbles in the delivery line and then experienced high resistance. Some of the Y-90 activity (approximately 13.2 mCi or 0.49 GBq) was delivered to the patient. Approximately 60% of the activity was in the administration set and catheter. No contamination of the IR suite or of any of the personnel occurred. All of the dose was either in the delivery system/catheter or the patient.
"No harm was done to the patient since the activity was delivered to the target organ and the dose did not exceed the prescribed dose.
"The referring physician and the patient were notified within 24 hours."
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.