Event Notification Report for November 21, 2022
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
11/20/2022 - 11/21/2022
EVENT NUMBERS
56237
56237
Agreement State
Event Number: 56237
Rep Org: Texas Dept of State Health Services
Licensee: CHI ST LUKES HEALTH BAYLOR
Region: 4
City: Houston State: TX
County:
License #: L06661
Agreement: Y
Docket:
NRC Notified By: Randall Redd
HQ OPS Officer: Ernest West
Licensee: CHI ST LUKES HEALTH BAYLOR
Region: 4
City: Houston State: TX
County:
License #: L06661
Agreement: Y
Docket:
NRC Notified By: Randall Redd
HQ OPS Officer: Ernest West
Notification Date: 11/23/2022
Notification Time: 11:30 [ET]
Event Date: 11/21/2022
Event Time: 00:00 [CST]
Last Update Date: 11/23/2022
Notification Time: 11:30 [ET]
Event Date: 11/21/2022
Event Time: 00:00 [CST]
Last Update Date: 11/23/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Werner, Greg (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Werner, Greg (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - UNDERDOSE OF YTTRIUM-90 SIR-SPHERES
The following information was provided by the Texas Department of State Health Services (the Department) via email:
"On November 23, 2022, the Department was notified by a licensee of a medical event involving Yttrium-90 Sir-Spheres. The procedure took place on November 21 and was thought to occur without incident, but when the tubing was measured on November 22, they found significant activity indicating that only 61.6 percent of the intended activity or material had been inserted into the patient. The intended activity to be inserted was 13.4 mCi and the actual activity delivered was 8.26 mCi. The room was surveyed after the procedure and no significant leakage or contamination was found. The patient and prescribing physician should be notified today. Further information will be supplied per SA-300. The investigation is ongoing."
Texas Incident Number: 9965
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 information was provided by the Texas Department of State Health Services (the Department) via email:
"On November 23, 2022, the Department was notified by a licensee of a medical event involving Yttrium-90 Sir-Spheres. The procedure took place on November 21 and was thought to occur without incident, but when the tubing was measured on November 22, they found significant activity indicating that only 61.6 percent of the intended activity or material had been inserted into the patient. The intended activity to be inserted was 13.4 mCi and the actual activity delivered was 8.26 mCi. The room was surveyed after the procedure and no significant leakage or contamination was found. The patient and prescribing physician should be notified today. Further information will be supplied per SA-300. The investigation is ongoing."
Texas Incident Number: 9965
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.