Event Notification Report for February 26, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
02/25/2021 - 02/26/2021
Non-Agreement State
Event Number: 55107
Rep Org: Kootenai Health
Licensee: Kootenai Health
Region: 4
City: Coeur d`Alene State: ID
County:
License #: 11-27307-01
Agreement: N
Docket:
NRC Notified By: Rhonda Powell
HQ OPS Officer: Bethany Cecere
Notification Date: 02/18/2021
Notification Time: 17:02 [ET]
Event Date: 02/18/2021
Event Time: 10:40 [MST]
Last Update Date: 02/18/2021
Emergency Class: Non Emergency
10 CFR Section:
35.3045(a)(1) - Dose <> Prescribed Dosage
Person (Organization):
DIXON, JOHN (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
Event Text
NON-AGREEMENT STATE REPORT - RADIOPHARMECEUTICAL UNDER DOSE
The following was received via phone from the licensee:
At 1040 MST, on 2/18/21, a patient received less than the prescribed dose of 130 gray to the liver due to the catheter and device connection coming apart. The isotope was Y-90 glass microspheres. The calculated dose to the patient was 62.2 gray (47.9 percent of the prescribed dose). All non-delivered material was collected in the catheter and on absorbent material for decay and return to the manufacturer. The patient was notified of the under dose.
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.