Event Notification Report for November 14, 2019
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
11/13/2019 - 11/14/2019
EVENT NUMBERS
54395
Agreement State
Event Number: 54395
Rep Org: TENNESSEE DIV OF RAD HEALTH
Licensee: VANDERBILT UNIVERSITY
Region: 1
City: NASHVILLE State: TN
County:
License #: R-19266
Agreement: Y
Docket:
NRC Notified By: ANDREW HOLCOMB
HQ OPS Officer: HOWIE CROUCH
Licensee: VANDERBILT UNIVERSITY
Region: 1
City: NASHVILLE State: TN
County:
License #: R-19266
Agreement: Y
Docket:
NRC Notified By: ANDREW HOLCOMB
HQ OPS Officer: HOWIE CROUCH
Notification Date: 11/20/2019
Notification Time: 09:28 [ET]
Event Date: 11/14/2019
Event Time: 00:00 [EST]
Last Update Date: 11/20/2019
Notification Time: 09:28 [ET]
Event Date: 11/14/2019
Event Time: 00:00 [EST]
Last Update Date: 11/20/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
CHRISTOPHER CAHILL (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
SOPHIE HOLIDAY (NMSS DAY)
CHRISTOPHER CAHILL (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
SOPHIE HOLIDAY (NMSS DAY)
TENNESSEE AGREEMENT STATE REPORT - MEDICAL EVENT THAT RESULTED IN SKIN INJURY
The following information was received from the state of Tennessee via email:
"Patient treated with Lutathera (Lu-177 dotatate) on November 14, 2019. It was determined during her infusion that the Foley catheter was leaking. After the leak was identified, proper decontamination procedures were performed. The patient was instructed upon discharge that there was a chance for potential skin injury. Licensee reported that the estimated skin dose was 7 Gray (Gy). On November 18, 2019, the patient informed her provider that there was skin irritation in the peri-gluteal and peri-labia areas. It was determined that this was skin injury consistent with radiation injury. A follow-up report will be submitted upon receipt of a written report from the licensee."
Tennessee Event Report ID No.: TN-19-161
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 information was received from the state of Tennessee via email:
"Patient treated with Lutathera (Lu-177 dotatate) on November 14, 2019. It was determined during her infusion that the Foley catheter was leaking. After the leak was identified, proper decontamination procedures were performed. The patient was instructed upon discharge that there was a chance for potential skin injury. Licensee reported that the estimated skin dose was 7 Gray (Gy). On November 18, 2019, the patient informed her provider that there was skin irritation in the peri-gluteal and peri-labia areas. It was determined that this was skin injury consistent with radiation injury. A follow-up report will be submitted upon receipt of a written report from the licensee."
Tennessee Event Report ID No.: TN-19-161
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.