Event Notification Report for May 20, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
05/19/2021 - 05/20/2021
EVENT NUMBERS
55268
55268
Hospital
Event Number: 55268
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: Brian P. Smith
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: Brian P. Smith
Notification Date: 05/20/2021
Notification Time: 16:53 [ET]
Event Date: 05/20/2021
Event Time: 09:43 [PST]
Last Update Date: 05/20/2021
Notification Time: 16:53 [ET]
Event Date: 05/20/2021
Event Time: 09:43 [PST]
Last Update Date: 05/20/2021
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):
NMSS_EVENTS_NOTIFICATION (EMAIL)
YOUNG, CALE (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
YOUNG, CALE (R4DO)
EN Revision Imported Date: 6/17/2021
EN Revision Text: PATIENT UNDERDOSE
The following e-mail was received from the Radiation Safety Officer (RSO) at Kootenai Health:
"A misadministration occurred at Kootenai Health in the Interventional Radiology Lab (ID 83814) during a Therasphere Y-90 Microsphere treatment. The prescribed dose was 66.36 mCi to segment 8 of the liver. The microspheres infusion started at 0943 PST when the micropsheres became visually clumped in the tubing of the administration set (distal to the box, prior to the microcatheter connection). Troubleshooting methods were performed, but the microspheres did not move through the tubing with multiple saline flush attempts. The infusion was aborted at 1016 PST. The room was surveyed per protocol and there was no contamination. The jar containing the tubing and microcatheter were measured per protocol. Calculations determined the patient received 12.8 mCi which was 20 percent of the prescribed dose. The RSO was notified at 1058 PST, the referring physician [was notified] at 1128 PST, and the patient [was notified] at 1150 PST."
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: PATIENT UNDERDOSE
The following e-mail was received from the Radiation Safety Officer (RSO) at Kootenai Health:
"A misadministration occurred at Kootenai Health in the Interventional Radiology Lab (ID 83814) during a Therasphere Y-90 Microsphere treatment. The prescribed dose was 66.36 mCi to segment 8 of the liver. The microspheres infusion started at 0943 PST when the micropsheres became visually clumped in the tubing of the administration set (distal to the box, prior to the microcatheter connection). Troubleshooting methods were performed, but the microspheres did not move through the tubing with multiple saline flush attempts. The infusion was aborted at 1016 PST. The room was surveyed per protocol and there was no contamination. The jar containing the tubing and microcatheter were measured per protocol. Calculations determined the patient received 12.8 mCi which was 20 percent of the prescribed dose. The RSO was notified at 1058 PST, the referring physician [was notified] at 1128 PST, and the patient [was notified] at 1150 PST."
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.