ENS 48441
ENS Event | |
|---|---|
04:00 May 24, 2011 | |
| Title | |
| Event Description | The following information was obtained from the State of Georgia via facsimile:
Description of Event: A spill involving Y-90 microspheres (SIR-Spheres) that occurred on May 24, 2011 at Emory University Hospital [and] was reported by the Deputy Radiation Safety Officer. During an embolization treatment using Y-90 microspheres, resistance was encountered when flushing the catheter following the initial successful microsphere administration. The authorized user examined the catheter which was found to be occluded. Preparations were made to continue the administration with a second measured dose, but this was halted when further examination showed evidence of a leak between the Y-90 vial and the catheter. The procedure was postponed until contamination controls were complete. The patient received the completion of the prescribed dose pursuant to the Authorized User's written directives when the Interventional Suite was available for use on the following day. Describe clean-up actions taken by RCP [Georgia Radiation Control Program]: No action performed by RCP but the licensee sealed the Y-90 shielding and cart and removed [them] for decay and evaluation. The floor and equipment were decontaminated by licensee radiation safety staff. List radiation measurements taken by RCP: No measurements performed by the RCP but the licensee initiated spill containment procedures [and surveyed] the staff before allowing anyone to exit the room. Some minor contamination was discovered on staff clothing and shoes, but no contamination was detected on the skin of staff after removal of affected items. The deputy RSO surveyed the patient and had a bremsstrahlung scan of patient. No contamination was found on the patient during the scan. List any other actions required of RCP: The licensee is storing all waste from this event for decay and subsequent investigation. Georgia Incident Summary number GA-2011-61i. |
| Where | |
|---|---|
| Emory University Atlanta, Georgia (NRC Region 1) | |
| License number: | GA-153-1 |
| Organization: | Georgia Radioactive Material Pgm |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+12484.05 h520.169 days <br />74.31 weeks <br />17.101 months <br />) | |
| Opened: | Joel Mims 08:03 Oct 25, 2012 |
| NRC Officer: | Howie Crouch |
| Last Updated: | Oct 25, 2012 |
| 48441 - NRC Website | |
Emory University with Agreement State | |
WEEKMONTHYEARENS 569462024-02-01T05:00:0001 February 2024 05:00:00
[Table view]Agreement State Lost Source ENS 560072022-07-20T04:00:00020 July 2022 04:00:00 Agreement State Dose Misadministration ENS 558502022-04-11T04:00:00011 April 2022 04:00:00 Agreement State Lost/Missing Source ENS 549742020-10-29T04:00:00029 October 2020 04:00:00 Agreement State Dose Delivered Differs by Greater than 20 Percent ENS 549672020-10-23T04:00:00023 October 2020 04:00:00 Agreement State Dose Delivered Differs by Greater than 20 Percent ENS 534682018-06-21T04:00:00021 June 2018 04:00:00 Agreement State En Revision Imported Date 7/3/2018 ENS 529792017-08-24T04:00:00024 August 2017 04:00:00 Agreement State Agreement State Report - Dose Delivered 20% Greater than Prescribed and Greater than 50 Rem to the Targeted Area ENS 499172014-02-27T04:00:00027 February 2014 04:00:00 Agreement State Agreement State Report - Yttrium 90 Medical Event ENS 484412011-05-24T04:00:00024 May 2011 04:00:00 Agreement State Agreement State Report - Y-90 Therasphere Spill ENS 452462009-08-05T04:00:0005 August 2009 04:00:00 Agreement State Agreement State Report - Medical Dose Different than Prescribed ENS 443312008-05-31T04:00:00031 May 2008 04:00:00 Agreement State Agreement State - Possible Overexposure 2024-02-01T05:00:00 | |