ENS 55387

v t e ENS Event
05:00 Jul 29, 2021
Title	Medical Event
Event Description	The following was received from the Kentucky Department of Radiation Control, Radiation Health Branch (RHB) via email: At approximately 1230 CDT on 7/29/21 the Hospital [Radiation Safety Officer] RSO called RHB to report a failure of a Therasphere Y-90 administration kit. Authorized User (AU) indicated an almost immediate failure to administer the dose. There was no flow into the administration catheter. Saline observed exiting the administration set up into an overflow vial. After adjusting the pressure and a second attempt failed, a call was placed to the administration kit representative. Three more attempts failed. The AU decided to stop the process and remove the administration catheter. Patient procedure was stopped. Not rescheduled at this time. A survey of the vial and administration set up, and multiple patient surveys seem to indicate that no dose was administered to the patient. Y-90 set up and vials were packaged and stored into appropriate waste. No contamination, no release of material. No patient administration. Expected 4.15 GBq and received none. Licensee suspects an administration set up kit failure. Licensee will provide full reports to the RHB staff within 15 days. KY Event Report ID: 210002 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 55387 +/-
Where
St Elizabeth - Edgewood Edgewood, Kentucky (NRC Region 1)
License number:	202-152-27
Organization:	Kentucky Dept Of Radiation Control
Reporting

Agreement State
Time - Person (Reporting Time:+34.17 h1.424 days <br />0.203 weeks <br />0.0468 months <br />)
Opened:	Angela Wilbers 15:10 Jul 30, 2021
NRC Officer:	Jeffrey Whited
Last Updated:	Jul 30, 2021
55387 - NRC Website
v • d • e

v t e Emergency Notification System
St Elizabeth - Edgewood with Agreement State
WEEKMONTHYEAR2021-07-29T05:00:00 [Table view]
[ENS list for St Elizabeth - Edgewood]

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