Event Notification Report for April 16, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
04/15/2021 - 04/16/2021
Non-Agreement State
Event Number: 55196
Rep Org: Department of Veteran Affairs
Licensee: Department of Veteran Affairs
Region: 3
City: Oklahoma City State: OK
County:
License #: Master Materials License
Agreement: Y
Docket:
NRC Notified By: Curtis Kwasniewski
HQ OPS Officer: Jeffrey Whited
Licensee: Department of Veteran Affairs
Region: 3
City: Oklahoma City State: OK
County:
License #: Master Materials License
Agreement: Y
Docket:
NRC Notified By: Curtis Kwasniewski
HQ OPS Officer: Jeffrey Whited
Notification Date: 04/16/2021
Notification Time: 15:21 [ET]
Event Date: 04/16/2021
Event Time: 00:00 [CDT]
Last Update Date: 04/16/2021
Notification Time: 15:21 [ET]
Event Date: 04/16/2021
Event Time: 00:00 [CDT]
Last Update Date: 04/16/2021
Emergency Class: Non Emergency
10 CFR Section:
35.3045(a)(1) - Dose <> Prescribed Dosage
10 CFR Section:
35.3045(a)(1) - Dose <> Prescribed Dosage
Person (Organization):
STOEDTER, KARLA (R3DO)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
STOEDTER, KARLA (R3DO)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 5/14/2021
EN Revision Text: MEDICAL EVENT - UNDERDOSAGE
The following is a summary of a call from the Department of Veteran Affairs:
During a Y-90 SIR-Spheres radioembolization of the liver, the patient was delivered 6.2 milliCuries of the prescribed 8.1 milliCurie dose, for an underdosage of 23 percent.
The patient is aware of the underdosage. The cause of the underdosage is currently under investigation.
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.
EN Revision Text: MEDICAL EVENT - UNDERDOSAGE
The following is a summary of a call from the Department of Veteran Affairs:
During a Y-90 SIR-Spheres radioembolization of the liver, the patient was delivered 6.2 milliCuries of the prescribed 8.1 milliCurie dose, for an underdosage of 23 percent.
The patient is aware of the underdosage. The cause of the underdosage is currently under investigation.
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.
Agreement State
Event Number: 55198
Rep Org: ARIZONA DEPT OF HEALTH SERVICES
Licensee: Arizona Center for Cancer Care
Region: 4
City: Phoenix State: AZ
County:
License #: 07-615
Agreement: Y
Docket:
NRC Notified By: Brian Goretzki
HQ OPS Officer: Lloyd Desotell
Licensee: Arizona Center for Cancer Care
Region: 4
City: Phoenix State: AZ
County:
License #: 07-615
Agreement: Y
Docket:
NRC Notified By: Brian Goretzki
HQ OPS Officer: Lloyd Desotell
Notification Date: 04/17/2021
Notification Time: 17:41 [ET]
Event Date: 04/16/2021
Event Time: 00:00 [MST]
Last Update Date: 04/17/2021
Notification Time: 17:41 [ET]
Event Date: 04/16/2021
Event Time: 00:00 [MST]
Last Update Date: 04/17/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
PICK, GREG (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
PICK, GREG (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 5/17/2021
EN Revision Text: AGREEMENT STATE REPORT - LEAKING SEALED SOURCE
The following was received by the Arizona Department of Health Services (the Department) via email:
"The Department received notification from the licensee on April 16, 2021, that a sealed source leak test for a Cs-137 vial source showed that removable contamination was present. The source was wiped and tested repeatedly and showed contamination each time, with an activity level of 0.008 microCuries or greater. The specific source information is as follows:
"Manufacturer: Eckert & Ziegler
Isotope: Cs-137
Reference Date: 1 September 2011
Activity contained: 205.2 microCuries
Source No: 1523-2-4
"The Department has requested additional information and continues to investigate the event."
Arizona Incident No.: 21-003
EN Revision Text: AGREEMENT STATE REPORT - LEAKING SEALED SOURCE
The following was received by the Arizona Department of Health Services (the Department) via email:
"The Department received notification from the licensee on April 16, 2021, that a sealed source leak test for a Cs-137 vial source showed that removable contamination was present. The source was wiped and tested repeatedly and showed contamination each time, with an activity level of 0.008 microCuries or greater. The specific source information is as follows:
"Manufacturer: Eckert & Ziegler
Isotope: Cs-137
Reference Date: 1 September 2011
Activity contained: 205.2 microCuries
Source No: 1523-2-4
"The Department has requested additional information and continues to investigate the event."
Arizona Incident No.: 21-003
Agreement State
Event Number: 55214
Rep Org: WA OFFICE OF RADIATION PROTECTION
Licensee: Virginia Mason Franciscan Health
Region: 4
City: Seattle State: WA
County:
License #: WN-M048-1
Agreement: Y
Docket:
NRC Notified By: Tristan Hay
HQ OPS Officer: Kerby Scales
Licensee: Virginia Mason Franciscan Health
Region: 4
City: Seattle State: WA
County:
License #: WN-M048-1
Agreement: Y
Docket:
NRC Notified By: Tristan Hay
HQ OPS Officer: Kerby Scales
Notification Date: 04/26/2021
Notification Time: 15:15 [ET]
Event Date: 04/16/2021
Event Time: 00:00 [PDT]
Last Update Date: 04/26/2021
Notification Time: 15:15 [ET]
Event Date: 04/16/2021
Event Time: 00:00 [PDT]
Last Update Date: 04/26/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
PROULX, DAVID (R4DO)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
PROULX, DAVID (R4DO)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 5/26/2021
EN Revision Text: AGREEMENT STATE REPORT - PATIENT UNDERDOSE
The following is a summary of an email received the State of Washington:
The licensee reported a medical event involving an underdose administration of Y-90 Theraspheres on April 16, 2021. The event resulted in an underdose to the liver. Two vials of Y-90 were to be delivered to two different locations in the liver, however surveys after injection of both vials revealed not all activity in vials made it into the patient. The planned activity for each dose was 0.79 GBq. Post treatment measurement of percent dose delivered for dose `A' and dose `B' was 60 percent and 76 percent, respectively. Gamma camera imagining confirmed no Y-90 Theraspheres in the dose-vial. However, imaging visualized activity retained in the delivery tubing. Routine post-imaging demonstrated microsphere distribution in liver segments 4A and 4B. The activity delivered was 0.465 GBq and 0.594 GBq, respectively.
Washington State Incident Number WA-21-008.
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.
EN Revision Text: AGREEMENT STATE REPORT - PATIENT UNDERDOSE
The following is a summary of an email received the State of Washington:
The licensee reported a medical event involving an underdose administration of Y-90 Theraspheres on April 16, 2021. The event resulted in an underdose to the liver. Two vials of Y-90 were to be delivered to two different locations in the liver, however surveys after injection of both vials revealed not all activity in vials made it into the patient. The planned activity for each dose was 0.79 GBq. Post treatment measurement of percent dose delivered for dose `A' and dose `B' was 60 percent and 76 percent, respectively. Gamma camera imagining confirmed no Y-90 Theraspheres in the dose-vial. However, imaging visualized activity retained in the delivery tubing. Routine post-imaging demonstrated microsphere distribution in liver segments 4A and 4B. The activity delivered was 0.465 GBq and 0.594 GBq, respectively.
Washington State Incident Number WA-21-008.
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.