Event Notification Report for August 22, 2024
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
08/21/2024 - 08/22/2024
EVENT NUMBERS
57286
57286
Agreement State
Event Number: 57286
Rep Org: Virginia Rad Materials Program
Licensee: Virginia Commonwealth University
Region: 1
City: Richmond State: VA
County:
License #: 760-215-1
Agreement: Y
Docket:
NRC Notified By: Karen Shelton
HQ OPS Officer: Brian P. Smith
Licensee: Virginia Commonwealth University
Region: 1
City: Richmond State: VA
County:
License #: 760-215-1
Agreement: Y
Docket:
NRC Notified By: Karen Shelton
HQ OPS Officer: Brian P. Smith
Notification Date: 08/23/2024
Notification Time: 15:30 [ET]
Event Date: 08/22/2024
Event Time: 13:30 [EDT]
Last Update Date: 08/23/2024
Notification Time: 15:30 [ET]
Event Date: 08/22/2024
Event Time: 13:30 [EDT]
Last Update Date: 08/23/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Lilliendahl, Jon (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Lilliendahl, Jon (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - DOSE ADMINISTERED TO WRONG SEGMENT OF LIVER
The following information was received via email from the Virginia Radiation Materials Program (VRMP):
"At approximately 1500 EDT on 8/22/2024, the VRMP was notified by the radiation safety officer (RSO) for Virginia Commonwealth University of a medical event involving a Y-90 TheraSpheres liver treatment. The event occurred on 8/22/24, at 1330 EDT. The written directive prescribed 215 Gy to segment 'A' of the liver and 142 Gy to segment 'B'. During the treatment, the Y-90 dose was administered to the wrong segment of the left hepatic lobe, segment 'A' received dose intended for segment 'B'. The prescribed dose for segment 'A' was 215 Gy (2.072 GBq) and that segment received 114Gy (1.369 GBq), which is less by 47 percent. This was realized immediately, and the procedure was ended without administering the other dose. The authorized user immediately notified the RSO who then notified the VRMP. Per the RSO, the referring physician has been notified and the patient's treatment will continue once appropriate dose calculation can be done. VRMP will follow up with an investigation."
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 received via email from the Virginia Radiation Materials Program (VRMP):
"At approximately 1500 EDT on 8/22/2024, the VRMP was notified by the radiation safety officer (RSO) for Virginia Commonwealth University of a medical event involving a Y-90 TheraSpheres liver treatment. The event occurred on 8/22/24, at 1330 EDT. The written directive prescribed 215 Gy to segment 'A' of the liver and 142 Gy to segment 'B'. During the treatment, the Y-90 dose was administered to the wrong segment of the left hepatic lobe, segment 'A' received dose intended for segment 'B'. The prescribed dose for segment 'A' was 215 Gy (2.072 GBq) and that segment received 114Gy (1.369 GBq), which is less by 47 percent. This was realized immediately, and the procedure was ended without administering the other dose. The authorized user immediately notified the RSO who then notified the VRMP. Per the RSO, the referring physician has been notified and the patient's treatment will continue once appropriate dose calculation can be done. VRMP will follow up with an investigation."
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.