ENS 54442

v t e ENS Event
05:00 Nov 22, 2019
Title	Agreement State Report - Equipment Failure During Medical Treatment
Event Description	The following was received from the Florida Bureau of Radiation Control (the Bureau) via email: At [licensee], on or around 1745 EST 22 November 2019, a male patient being treated with Y-90 theraspheres had a blockage on the catheter. The Interventional Radiologist increased the pressure on the line, rupturing the intubation tube. No contamination of staff, only patient. Decontamination of the room and patient followed, no contamination on skin, only gown and tube. Vials were disposed of with waste, so no batch numbers of spheres are available at this time. Problems with imaging occurred, so there are no images at this time. The Radiation Safety Officer (RSO) has asked for reports with more information from Interventional Radiologist (IR) and Radiation Oncologist Authorized User (ROAU). IR and ROAU disagree on how much activity the patient received before the rupture; patient was prescribed 15 mCi. Patient will return for further treatment. The Bureau has been notified and an inspector will be assigned to investigate. Incident Number: FL19-141 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.

ENS 54442 +/-
Where
University Of Miami Miami, Florida (NRC Region 1)
License number:	1319-1
Organization:	Florida Bureau Of Radiation Control
Reporting

Agreement State
Time - Person (Reporting Time:+513.65 h21.402 days <br />3.057 weeks <br />0.704 months <br />)
Opened:	Matthew Senison 14:39 Dec 13, 2019
NRC Officer:	Thomas Kendzia
Last Updated:	Dec 13, 2019
54442 - NRC Website
v • d • e

v t e Emergency Notification System
University Of Miami with Agreement State
WEEKMONTHYEAR2019-11-22T05:00:00 [Table view]
[ENS list for University Of Miami]

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