Event Notification Report for May 01, 2023
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
04/30/2023 - 05/01/2023
EVENT NUMBERS
56500
56500
Agreement State
Event Number: 56500
Rep Org: OR Dept of Health Rad Protection
Licensee: Sacred Heart Medical Center
Region: 4
City: Springfield State: OR
County:
License #: 90270
Agreement: Y
Docket:
NRC Notified By: Hillary Haskins
HQ OPS Officer: John Russell
Licensee: Sacred Heart Medical Center
Region: 4
City: Springfield State: OR
County:
License #: 90270
Agreement: Y
Docket:
NRC Notified By: Hillary Haskins
HQ OPS Officer: John Russell
Notification Date: 05/02/2023
Notification Time: 19:20 [ET]
Event Date: 05/01/2023
Event Time: 18:56 [PDT]
Last Update Date: 05/02/2023
Notification Time: 19:20 [ET]
Event Date: 05/01/2023
Event Time: 18:56 [PDT]
Last Update Date: 05/02/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Gaddy, Vincent (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Gaddy, Vincent (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - MEDICAL UNDERDOSE
The following information was provided by the Oregon Health Authority via email:
"Upon completion of [Yttrium] Y-90 Therasphere delivery [to a patient] and completion of post-treatment template measurements, it was noted that the delivery ratio appeared to be below 80%. The technologist who was involved in delivery contacted the authorized user who came and reviewed the information. Both the authorized user and Boston Scientific representative, who was present during delivery, felt that an error had been made in post-treatment measurements, so they were repeated both that day and the following.
"Nuclear medicine staff performed [single photon emission computed tomography with a computed tomography] SPECT/CT imaging of the Nalgene container. This imaging was reviewed on 5/1/23 and it was determined that activity was remaining in the delivery set tubing. Imaging was reviewed with the Assistant [radiation safety officer] RSO, and it was determined that a Medical Event had occurred. Per [the assistant RSO], the Medical Event was reported to the Oregon Health Authority on 5/2/23.
"The Authorized User, communicated the situation with the patient and is confident that no adverse effect has occurred based on calculated treatment thresholds and tumor burden.
"The authorized user reviewed the SPECT/CT imaging and will participate in mitigation."
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 Oregon Health Authority via email:
"Upon completion of [Yttrium] Y-90 Therasphere delivery [to a patient] and completion of post-treatment template measurements, it was noted that the delivery ratio appeared to be below 80%. The technologist who was involved in delivery contacted the authorized user who came and reviewed the information. Both the authorized user and Boston Scientific representative, who was present during delivery, felt that an error had been made in post-treatment measurements, so they were repeated both that day and the following.
"Nuclear medicine staff performed [single photon emission computed tomography with a computed tomography] SPECT/CT imaging of the Nalgene container. This imaging was reviewed on 5/1/23 and it was determined that activity was remaining in the delivery set tubing. Imaging was reviewed with the Assistant [radiation safety officer] RSO, and it was determined that a Medical Event had occurred. Per [the assistant RSO], the Medical Event was reported to the Oregon Health Authority on 5/2/23.
"The Authorized User, communicated the situation with the patient and is confident that no adverse effect has occurred based on calculated treatment thresholds and tumor burden.
"The authorized user reviewed the SPECT/CT imaging and will participate in mitigation."
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.