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. |
| 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 | |
St Elizabeth - Edgewood with Agreement State | |
WEEKMONTHYEARENS 553872021-07-29T05:00:00029 July 2021 05:00:00
[Table view]Agreement State Medical Event 2021-07-29T05:00:00 | |