Event Notification Report for July 12, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
07/11/2021 - 07/12/2021
EVENT NUMBERS
55441
55441
Agreement State
Event Number: 55441
Rep Org: TEXAS DEPT OF STATE HEALTH SERVICES
Licensee: The University of Texas MD Anderson Cancer Center
Region: 4
City: Houston State: TX
County:
License #: L 00466
Agreement: Y
Docket:
NRC Notified By: Matt Kennington
HQ OPS Officer: Mike Stafford
Licensee: The University of Texas MD Anderson Cancer Center
Region: 4
City: Houston State: TX
County:
License #: L 00466
Agreement: Y
Docket:
NRC Notified By: Matt Kennington
HQ OPS Officer: Mike Stafford
Notification Date: 08/31/2021
Notification Time: 17:02 [ET]
Event Date: 07/12/2021
Event Time: 00:00 [CDT]
Last Update Date: 08/31/2021
Notification Time: 17:02 [ET]
Event Date: 07/12/2021
Event Time: 00:00 [CDT]
Last Update Date: 08/31/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
JOSEY, JEFFREY (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
WILLIAMS, KEVIN (NMSS)
JOSEY, JEFFREY (R4)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
WILLIAMS, KEVIN (NMSS)
EN Revision Imported Date: 9/30/2021
EN Revision Text: AGREEMENT STATE - INCORRECT RADIOPHARMACEUTICAL ADMINISTERED
The following was received from the Texas Department of State Health Services (the Agency) via email:
"On August 31, 2021, the Agency received a notification from the Nuclear Regulatory Commission (NRC) stating that a Missouri supplier of radiopharmaceuticals had reported a misadministration that occurred on July 12, 2021, with one of their products at a Texas licensee. The licensee contacted the Agency to report the event shortly after receiving the notification from the NRC. The licensee stated that a patient was to receive 0.041 mCi of Th-227 with enzymes to affect breast cancer but was given 0.041 mCi of Th-227 with enzymes to affect mesothelioma. The event resulted in approximately 6 Gy dose to the liver. The patient refused a post therapy scan and the licensee was not able to confirm that the radiopharmaceutical went to the correct tissue in the body. The mislabeling was discovered by the radiopharmaceutical supplier who then notified the licensee that the drug administered was not correct. The licensee has notified the patient and physician. Additional information will be provided as it is received in accordance with SA-300."
Texas Incident Number: 9882
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 - INCORRECT RADIOPHARMACEUTICAL ADMINISTERED
The following was received from the Texas Department of State Health Services (the Agency) via email:
"On August 31, 2021, the Agency received a notification from the Nuclear Regulatory Commission (NRC) stating that a Missouri supplier of radiopharmaceuticals had reported a misadministration that occurred on July 12, 2021, with one of their products at a Texas licensee. The licensee contacted the Agency to report the event shortly after receiving the notification from the NRC. The licensee stated that a patient was to receive 0.041 mCi of Th-227 with enzymes to affect breast cancer but was given 0.041 mCi of Th-227 with enzymes to affect mesothelioma. The event resulted in approximately 6 Gy dose to the liver. The patient refused a post therapy scan and the licensee was not able to confirm that the radiopharmaceutical went to the correct tissue in the body. The mislabeling was discovered by the radiopharmaceutical supplier who then notified the licensee that the drug administered was not correct. The licensee has notified the patient and physician. Additional information will be provided as it is received in accordance with SA-300."
Texas Incident Number: 9882
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.