Event Notification Report for September 02, 2021
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
09/01/2021 - 09/02/2021
EVENT NUMBERS
55449
55449
Agreement State
Event Number: 55449
Rep Org: VIRGINIA RAD MATERIALS PROGRAM
Licensee: Inova Fairfax Medical Campus
Region: 1
City: Fairfax State: VA
County:
License #: 610-116-1
Agreement: Y
Docket:
NRC Notified By: Asfaw Fenta
HQ OPS Officer: Donald Norwood
Licensee: Inova Fairfax Medical Campus
Region: 1
City: Fairfax State: VA
County:
License #: 610-116-1
Agreement: Y
Docket:
NRC Notified By: Asfaw Fenta
HQ OPS Officer: Donald Norwood
Notification Date: 09/08/2021
Notification Time: 13:00 [ET]
Event Date: 09/02/2021
Event Time: 00:00 [EDT]
Last Update Date: 09/08/2021
Notification Time: 13:00 [ET]
Event Date: 09/02/2021
Event Time: 00:00 [EDT]
Last Update Date: 09/08/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
DENTEL, GLENN (R1)
RIVERA-CAPELLA, GRETCHEN (NMSS DAY)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
DENTEL, GLENN (R1)
RIVERA-CAPELLA, GRETCHEN (NMSS DAY)
NMSS_EVENTS_NOTIFICATION, (EMAIL)
EN Revision Imported Date: 10/8/2021
EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT INVOLVING Y-90 MICROSPHERES
The following information was received via E-mail:
"On September 7, 2021 at 1535 EDT, the Virginia Radioactive Materials Program (RMP) received a report from the licensee that a medical event involving Yttrium-90 microspheres occurred on September 2, 2021 (procedure date). The Authorized User (AU) discovered the event on September 3, 2021. According to the written directive, the prescribed dose to liver segments 2 and 3 was 130 Gy and to liver segments, 4 and 8 was also 130 Gy. After the procedure, the licensee discovered that the dose intended to liver segments 2 and 3 went to liver segment 4. As a result, liver segment 4 received the unintended dose of 54 Gy and the intended dose of 130 Gy for a sum of 184 Gy, which is a difference of 41.5 percent. The licensee reported that the cause of the event was a result of incorrect location of the delivery catheter and the patient was notified on September 3, 2021.
"The RMP will schedule to investigate the event and this report will be updated when the final investigation report is available."
Virginia Event Report ID No.: VA210005
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 - MEDICAL EVENT INVOLVING Y-90 MICROSPHERES
The following information was received via E-mail:
"On September 7, 2021 at 1535 EDT, the Virginia Radioactive Materials Program (RMP) received a report from the licensee that a medical event involving Yttrium-90 microspheres occurred on September 2, 2021 (procedure date). The Authorized User (AU) discovered the event on September 3, 2021. According to the written directive, the prescribed dose to liver segments 2 and 3 was 130 Gy and to liver segments, 4 and 8 was also 130 Gy. After the procedure, the licensee discovered that the dose intended to liver segments 2 and 3 went to liver segment 4. As a result, liver segment 4 received the unintended dose of 54 Gy and the intended dose of 130 Gy for a sum of 184 Gy, which is a difference of 41.5 percent. The licensee reported that the cause of the event was a result of incorrect location of the delivery catheter and the patient was notified on September 3, 2021.
"The RMP will schedule to investigate the event and this report will be updated when the final investigation report is available."
Virginia Event Report ID No.: VA210005
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.