ENS 55003

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v t e ENS Event
05:00 Nov 11, 2020
Title	Medical Report - Underdose
Event Description	The following was received from the State of Kentucky via email: The Kentucky Radiation Health Branch was notified by the Radiation Safety Officer of a medical event at Norton Hospital Interventional Radiology Downtown Campus, Louisville KY (RML No. 202-031-26). Deviation from Y-90 Therasphere treatment dose to a patient was immediately identified due to a leak between the administration kit and the microcatheter used in administration of the dose. The situation was remedied by tightening the connection at the junction, and no further loss of material was observed. Spillage was confined to patient drape and follow-up surveys for external contamination on the patient and staff present were conducted. The room and staff were subsequently cleared of any radioactive contamination. The patient dose assessment was estimated using the patient waste and the spill waste and it was determined that the delivered dose was 93 Gy which was 68 percent of the prescribed dose of 135 Gy. Initial root cause analysis indicated that the administration set received from the manufacturer was a different kit from the previous set, and a mismatch resulted in a leaky junction. The licensee has contacted the manufacturer (Boston Scientific BTG) to resolve this situation. Kentucky Event Report ID No.: KY200006 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 55003 +/-
Where
Norton Hospital Downtown Campus Louisville, Kentucky (NRC Region 1)
License number:	2020-031-26
Organization:	Kentucky Dept Of Radiation Control
Reporting

Agreement State
Time - Person (Reporting Time:+150.67 h6.278 days <br />0.897 weeks <br />0.206 months <br />)
Opened:	Anjan Bhattacharyya 11:40 Nov 17, 2020
NRC Officer:	Brian Lin
Last Updated:	Nov 17, 2020
55003 - NRC Website
v • d • e

v t e Emergency Notification System
Norton Hospital Downtown Campus with Agreement State
WEEKMONTHYEAR2020-11-11T05:00:00 [Table view]
[ENS list for Norton Hospital Downtown Campus]

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