Event Notification Report for July 02, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
07/01/2021 - 07/02/2021
EVENT NUMBERS
55337
55337
Agreement State
Event Number: 55337
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: University of Pennsylvania
Region: 1
City: Philadelphia State: PA
County:
License #: PA-0131
Agreement: Y
Docket:
NRC Notified By: John S. Chippo
HQ OPS Officer: Lloyd Desotell
Licensee: University of Pennsylvania
Region: 1
City: Philadelphia State: PA
County:
License #: PA-0131
Agreement: Y
Docket:
NRC Notified By: John S. Chippo
HQ OPS Officer: Lloyd Desotell
Notification Date: 07/03/2021
Notification Time: 11:11 [ET]
Event Date: 07/02/2021
Event Time: 00:00 [EDT]
Last Update Date: 07/03/2021
Notification Time: 11:11 [ET]
Event Date: 07/02/2021
Event Time: 00:00 [EDT]
Last Update Date: 07/03/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
LILLIENDAHL, JON (R1)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
LILLIENDAHL, JON (R1)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 8/3/2021
EN Revision Text:
AGREEMENT STATE REPORT - PATIENT UNDER DOSE
The following was received via an email from the state of Pennsylvania:
"The Department [PA Bureau of Radiation Protection] received notification from a licensee on July 2, 2021 of a medical event involving a Y-90 TheraSphere. The licensee noted 71 percent of the prescribed dose of 30.8 millicuries was administered to the patient. A mechanical blockage occurred in the delivery system preventing spheres from exiting the administration vial. All material was contained in the delivery system, lines, and patient. Area monitoring confirmed that no leak occurred and no contamination of the work area. Nuclear Medicine imaging of the waste confirmed activity concentrated within the vial. The physician and patient have been notified. No adverse effects to the patient are anticipated. The Department is currently in contact with the licensee and will update this event as soon as more information is provided."
Pennsylvania Event Report ID No: PA210006
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 UNDER DOSE
The following was received via an email from the state of Pennsylvania:
"The Department [PA Bureau of Radiation Protection] received notification from a licensee on July 2, 2021 of a medical event involving a Y-90 TheraSphere. The licensee noted 71 percent of the prescribed dose of 30.8 millicuries was administered to the patient. A mechanical blockage occurred in the delivery system preventing spheres from exiting the administration vial. All material was contained in the delivery system, lines, and patient. Area monitoring confirmed that no leak occurred and no contamination of the work area. Nuclear Medicine imaging of the waste confirmed activity concentrated within the vial. The physician and patient have been notified. No adverse effects to the patient are anticipated. The Department is currently in contact with the licensee and will update this event as soon as more information is provided."
Pennsylvania Event Report ID No: PA210006
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.