Event Notification Report for February 13, 2023
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
02/12/2023 - 02/13/2023
EVENT NUMBERS
56353
56353
Agreement State
Event Number: 56353
Rep Org: Texas Dept of State Health Services
Licensee: The University of Texas Health Center at San Antonio
Region: 4
City: San Antonio State: TX
County:
License #: L 01279
Agreement: Y
Docket:
NRC Notified By: Chris Moore
HQ OPS Officer: Karen Cotton-Gross
Licensee: The University of Texas Health Center at San Antonio
Region: 4
City: San Antonio State: TX
County:
License #: L 01279
Agreement: Y
Docket:
NRC Notified By: Chris Moore
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 02/14/2023
Notification Time: 16:06 [ET]
Event Date: 02/13/2023
Event Time: 00:00 [CST]
Last Update Date: 02/15/2023
Notification Time: 16:06 [ET]
Event Date: 02/13/2023
Event Time: 00:00 [CST]
Last Update Date: 02/15/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Dixon, John (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Williams, Kevin (NMSS)
Dixon, John (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Williams, Kevin (NMSS)
AGREEMENT STATE REPORT - DOSE DELIVERED TO THE WRONG TREATMENT SITE
The following information was provided by the Texas Department of State Health Services (the Agency) via email:
"On February 13, 2023, the Agency was notified that a patient was prescribed to receive 35.74 mCi (1.32 GBq) of Y-90 microspheres to the right lobe of the liver. The dose was given to the left lobe (wrong lobe) of a patient during treatment on February 13, 2023. The dose delivered (36.48 mCi (1.35 GBq)) to the left lobe was within 20 percent of the prescribed dose. The dose that was delivered to the left lobe is also within 20 percent of the dose that would have been prescribed for the left lobe in 2 weeks according to the physician. The treatment was clinically insignificant to the patient as both lobes were to be treated with a pending remapping of the second lobe to confirm the dosage but both have similar tumor volumes. More information will be provided as it is obtained in accordance with SA-300.
NMED National Number: TX230005
Texas Incident Number: 9889
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 Agency) via email:
"On February 13, 2023, the Agency was notified that a patient was prescribed to receive 35.74 mCi (1.32 GBq) of Y-90 microspheres to the right lobe of the liver. The dose was given to the left lobe (wrong lobe) of a patient during treatment on February 13, 2023. The dose delivered (36.48 mCi (1.35 GBq)) to the left lobe was within 20 percent of the prescribed dose. The dose that was delivered to the left lobe is also within 20 percent of the dose that would have been prescribed for the left lobe in 2 weeks according to the physician. The treatment was clinically insignificant to the patient as both lobes were to be treated with a pending remapping of the second lobe to confirm the dosage but both have similar tumor volumes. More information will be provided as it is obtained in accordance with SA-300.
NMED National Number: TX230005
Texas Incident Number: 9889
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.