Event Notification Report for July 27, 2022
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
07/26/2022 - 07/27/2022
EVENT NUMBERS
56020
56020
Hospital
Event Number: 56020
Rep Org: VA National Health Physics Program
Licensee: Tibor Rubin VA Medical Center
Region: 3
City: Little Rock State: AR
County:
License #: 03-23853-01VA
Agreement: N
Docket:
NRC Notified By: Kim Wiebeck
HQ OPS Officer: Mike Stafford
Licensee: Tibor Rubin VA Medical Center
Region: 3
City: Little Rock State: AR
County:
License #: 03-23853-01VA
Agreement: N
Docket:
NRC Notified By: Kim Wiebeck
HQ OPS Officer: Mike Stafford
Notification Date: 07/28/2022
Notification Time: 15:12 [ET]
Event Date: 07/27/2022
Event Time: 11:15 [PDT]
Last Update Date: 07/28/2022
Notification Time: 15:12 [ET]
Event Date: 07/27/2022
Event Time: 11:15 [PDT]
Last Update Date: 07/28/2022
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):
Peterson, Hironori (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Peterson, Hironori (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
MEDICAL EVENT - PATIENT UNDERDOSE
The following report was received via email from the VA National Health Physics Program (NHPP):
"Tibor Rubin VA Medical Center, Long Beach, California, which holds Permit Number 04-00689-07 under the VA master materials license, reported the discovery of a medical event to NHPP at approximately 1450 CDT, July 27, 2022.
"A radium-223 dichloride (Xofigo(R)) therapy administration was performed at approximately 1115 PDT on July 27, 2022. The prescribed dosage was 211 microcuries, to be administered intravenously. Due to leakage at the IV 3-way stopcock, approximately only 160 microcuries was administered, resulting in about 75 percent of the prescribed dosage being delivered. This meets the reporting criteria of 10 CFR 35.3045 (a)(1)(i) and (a)(1)(i)(B).
"The patient and the referring physician have been notified. No harm is expected to the patient.
"NHPP will follow up with a written report in accordance with NRC requirements in 10 CFR 35.3045.
"NHPP notified our NRC Region III Project Manager, Bryan Parker."
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.
The following report was received via email from the VA National Health Physics Program (NHPP):
"Tibor Rubin VA Medical Center, Long Beach, California, which holds Permit Number 04-00689-07 under the VA master materials license, reported the discovery of a medical event to NHPP at approximately 1450 CDT, July 27, 2022.
"A radium-223 dichloride (Xofigo(R)) therapy administration was performed at approximately 1115 PDT on July 27, 2022. The prescribed dosage was 211 microcuries, to be administered intravenously. Due to leakage at the IV 3-way stopcock, approximately only 160 microcuries was administered, resulting in about 75 percent of the prescribed dosage being delivered. This meets the reporting criteria of 10 CFR 35.3045 (a)(1)(i) and (a)(1)(i)(B).
"The patient and the referring physician have been notified. No harm is expected to the patient.
"NHPP will follow up with a written report in accordance with NRC requirements in 10 CFR 35.3045.
"NHPP notified our NRC Region III Project Manager, Bryan Parker."
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.