Event Notification Report for March 13, 2026
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Event Text
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
03/12/2026 - 03/13/2026
EVENT NUMBERS
58185
58185
Agreement State
Event Number: 58185
Rep Org: Wisconsin Radiation Protection
Licensee: University of Wisconsin Madison
Region: 3
City: Madison State: WI
County:
License #: 025-1323-01
Agreement: Y
Docket:
NRC Notified By: Sarah Bouche
HQ OPS Officer: Karen Cotton
Licensee: University of Wisconsin Madison
Region: 3
City: Madison State: WI
County:
License #: 025-1323-01
Agreement: Y
Docket:
NRC Notified By: Sarah Bouche
HQ OPS Officer: Karen Cotton
Notification Date: 03/05/2026
Notification Time: 09:49 [ET]
Event Date: 03/04/2026
Event Time: 00:00 [CST]
Last Update Date: 03/05/2026
Notification Time: 09:49 [ET]
Event Date: 03/04/2026
Event Time: 00:00 [CST]
Last Update Date: 03/05/2026
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Edwards, Rhex (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Edwards, Rhex (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - EQUIPMENT FAILURE
The following information was provided by the Wisconsin Department of Health Services via email:
"The University of Wisconsin Madison (UWM) reported an equipment failure involving a Y-90 TheraSphere microsphere administration set (lot A182) which occurred on March 4, 2026. UWM reported the tubing was damaged when it was removed from the priming line and was unable to be connected to the patient's catheter. Since the dose vial had already been punctured in the set-up, the therapy was cancelled.
"The administration set was disassembled so that the dose vial could be put into waste without releasing any of the spheres. The faulty connectors were removed and given to the manufacturer's representative who was present. The UWM found an additional administration set from the same lot; this was pulled and will not be used. Areas of possible contamination were surveyed, and none were found."
Wisconsin Event Report ID No.: WI260006
The following information was provided by the Wisconsin Department of Health Services via email:
"The University of Wisconsin Madison (UWM) reported an equipment failure involving a Y-90 TheraSphere microsphere administration set (lot A182) which occurred on March 4, 2026. UWM reported the tubing was damaged when it was removed from the priming line and was unable to be connected to the patient's catheter. Since the dose vial had already been punctured in the set-up, the therapy was cancelled.
"The administration set was disassembled so that the dose vial could be put into waste without releasing any of the spheres. The faulty connectors were removed and given to the manufacturer's representative who was present. The UWM found an additional administration set from the same lot; this was pulled and will not be used. Areas of possible contamination were surveyed, and none were found."
Wisconsin Event Report ID No.: WI260006
Page Last Reviewed/Updated March 13, 2026, 04:46 am EDT