Event Notification Report for February 27, 2023
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
02/26/2023 - 02/27/2023
Agreement State
Event Number: 56407
Rep Org: Tennessee Div of Rad Health
Licensee: Methodist University Hospital
Region: 1
City: Memphis State: TN
County:
License #: #R-79009-K24
Agreement: Y
Docket:
NRC Notified By: ANDREW HOLCOMB
HQ OPS Officer: Caty Nolan
Licensee: Methodist University Hospital
Region: 1
City: Memphis State: TN
County:
License #: #R-79009-K24
Agreement: Y
Docket:
NRC Notified By: ANDREW HOLCOMB
HQ OPS Officer: Caty Nolan
Notification Date: 03/10/2023
Notification Time: 16:43 [ET]
Event Date: 02/27/2023
Event Time: 00:00 [EST]
Last Update Date: 03/10/2023
Notification Time: 16:43 [ET]
Event Date: 02/27/2023
Event Time: 00:00 [EST]
Last Update Date: 03/10/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Young, Matt (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Gupta Sarma, Trisha (NMSS DAY)
Young, Matt (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Gupta Sarma, Trisha (NMSS DAY)
AGREEMENT STATE REPORT - MEDICAL EVENT
The following information was provided by the Tennessee Division of Radiological Health via email:
"The misadministration occurred on 2/27/23 at Methodist Germantown Hospital in the interventional radiology (IR) suite. The procedure was a Y-90 treatment for 2 separate segments. Each segment had a different dose. All documentation and a checklist were appropriately filled out and the doses were documented. The physician was to the point in the procedure to ask for the first dose. The physician asked for the 'First Dose.' The dose was brought to the physician. The dose was verbally read out and [the physician] connected the dose and administered it. The result was a treatment of the small segment, but the large dose was given. Both segments were treated, but the doses were reversed. The doses of Y-90 were as follows:
"1st Prescribed Dose 79.95 Gy, Dose Given 474.7 Gy
"2nd Prescribed Dose 474.7 Gy, Dose Given 79.95 Gy
"Corrective actions will be sent with the follow-up NMED report."
State Event Report ID NO.: TN-23-013
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 Tennessee Division of Radiological Health via email:
"The misadministration occurred on 2/27/23 at Methodist Germantown Hospital in the interventional radiology (IR) suite. The procedure was a Y-90 treatment for 2 separate segments. Each segment had a different dose. All documentation and a checklist were appropriately filled out and the doses were documented. The physician was to the point in the procedure to ask for the first dose. The physician asked for the 'First Dose.' The dose was brought to the physician. The dose was verbally read out and [the physician] connected the dose and administered it. The result was a treatment of the small segment, but the large dose was given. Both segments were treated, but the doses were reversed. The doses of Y-90 were as follows:
"1st Prescribed Dose 79.95 Gy, Dose Given 474.7 Gy
"2nd Prescribed Dose 474.7 Gy, Dose Given 79.95 Gy
"Corrective actions will be sent with the follow-up NMED report."
State Event Report ID NO.: TN-23-013
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.
Agreement State
Event Number: 56383
Rep Org: Texas Dept of State Health Services
Licensee: Citizens Medical Center
Region: 4
City: Victoria State: TX
County:
License #: L 00283
Agreement: Y
Docket:
NRC Notified By: Chris Moore
HQ OPS Officer: Adam Koziol
Licensee: Citizens Medical Center
Region: 4
City: Victoria State: TX
County:
License #: L 00283
Agreement: Y
Docket:
NRC Notified By: Chris Moore
HQ OPS Officer: Adam Koziol
Notification Date: 02/28/2023
Notification Time: 07:02 [ET]
Event Date: 02/27/2023
Event Time: 00:00 [CST]
Last Update Date: 02/28/2023
Notification Time: 07:02 [ET]
Event Date: 02/27/2023
Event Time: 00:00 [CST]
Last Update Date: 02/28/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Vossmar, Patricia (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Vossmar, Patricia (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - STUCK SOURCE
The following information was provided by the Texas Department of State Health Services (the Agency) via email:
"On February 27, 2023, the Agency was sent a reciprocity notice that a service company was going to work in a hospital to repair a Elekta model 136146 Flexitron high dose rate remote afterloader unit (HDR) containing 10 Ci of Ir-192. The report indicated the source was stuck. The Agency contacted the hospital and determined that the source became stuck outside the HDR unit during the conduct of a dwell position accuracy check using the source position check ruler. This was conducted as a daily Quality Assurance (QA) check. The QA device transfer tube for the test was connected upside down, the connector was inverted, by error, which allowed the source to travel outside the tube and get stuck outside the vault below the ruler. The source could not be retrieved. There is no report of excess exposure to hospital staff and no medical procedure was being conducted. The unit was repaired and a report was issued by the service technician to determine if there is a design issue with the test equipment. Additional details will be sent in accordance with SA 300."
Texas Incident Number: I-9994
Texas NMED Number: TX23007
The following information was provided by the Texas Department of State Health Services (the Agency) via email:
"On February 27, 2023, the Agency was sent a reciprocity notice that a service company was going to work in a hospital to repair a Elekta model 136146 Flexitron high dose rate remote afterloader unit (HDR) containing 10 Ci of Ir-192. The report indicated the source was stuck. The Agency contacted the hospital and determined that the source became stuck outside the HDR unit during the conduct of a dwell position accuracy check using the source position check ruler. This was conducted as a daily Quality Assurance (QA) check. The QA device transfer tube for the test was connected upside down, the connector was inverted, by error, which allowed the source to travel outside the tube and get stuck outside the vault below the ruler. The source could not be retrieved. There is no report of excess exposure to hospital staff and no medical procedure was being conducted. The unit was repaired and a report was issued by the service technician to determine if there is a design issue with the test equipment. Additional details will be sent in accordance with SA 300."
Texas Incident Number: I-9994
Texas NMED Number: TX23007