Event Notification Report for March 03, 2022
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
03/02/2022 - 03/03/2022
EVENT NUMBERS
55766
55766
Agreement State
Event Number: 55766
Rep Org: PA Bureau of Radiation Protection
Licensee: Reading Hospital
Region: 1
City: Reading State: PA
County:
License #: PA-0023
Agreement: Y
Docket:
NRC Notified By: John Chippo
HQ OPS Officer: Thomas Herrity
Licensee: Reading Hospital
Region: 1
City: Reading State: PA
County:
License #: PA-0023
Agreement: Y
Docket:
NRC Notified By: John Chippo
HQ OPS Officer: Thomas Herrity
Notification Date: 03/04/2022
Notification Time: 11:23 [ET]
Event Date: 03/03/2022
Event Time: 00:00 [EST]
Last Update Date: 03/04/2022
Notification Time: 11:23 [ET]
Event Date: 03/03/2022
Event Time: 00:00 [EST]
Last Update Date: 03/04/2022
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: 4/4/2022
EN Revision Text: AGREEMENT STATE - UNDERDOSE
The following was received from the Commonwealth of Pennsylvania, Department of Environmental Protection (DEP) via e-mail:
"On March 3, 2022 a patient was receiving a Lutetium-177 (Lutatherar) treatment. During treatment, the vial lost pressure resulting in the inability to deliver the majority of the dose to the patient. Remedial measures were attempted, such as Dermabond and the addition of air, however, the procedure still could not continue, and it was terminated. No contamination was found outside of the delivery box. The prescribed dose was 200 milliCuries and it is estimated that the patient received 1.4 milliCuries. An investigation into the cause of the event is underway by the licensee. No adverse effects to the patient are noted at this time and the patient and prescribing physician have been informed. The DEP will update this event as soon as more information is provided."
PA Event Report ID No: PA220009
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 - UNDERDOSE
The following was received from the Commonwealth of Pennsylvania, Department of Environmental Protection (DEP) via e-mail:
"On March 3, 2022 a patient was receiving a Lutetium-177 (Lutatherar) treatment. During treatment, the vial lost pressure resulting in the inability to deliver the majority of the dose to the patient. Remedial measures were attempted, such as Dermabond and the addition of air, however, the procedure still could not continue, and it was terminated. No contamination was found outside of the delivery box. The prescribed dose was 200 milliCuries and it is estimated that the patient received 1.4 milliCuries. An investigation into the cause of the event is underway by the licensee. No adverse effects to the patient are noted at this time and the patient and prescribing physician have been informed. The DEP will update this event as soon as more information is provided."
PA Event Report ID No: PA220009
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.