ENS 56582

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v t e ENS Event
15:30 Jun 19, 2023
Title	Patient Underdose
Event Description	The following information was provided by the Arkansas Department of Health via email: On June 19, 2023, at approximately 1300 CDT, the licensee contacted the Arkansas Department of Health to report a medical event from Jefferson Regional Medical Center, Pine Bluff, Arkansas. The Radiation Safety Officer, Imaging Services Compliance Specialist, called to report a mishap with their first procedures with Y-90. It appears that their patient was to have received 19.8 Gray. However, due to equipment or patient issues the patient received only 6% (i.e. 2.6 Gray). The original injection was to have been 68.5 mCi. The report from the licensee is as follows: This is a termination of the Y-90 therapy due to stasis of the administration. 'Based on dosimeter readings of the Y-90 vial, and Geiger-Mueller meter measurements of the equipment, the microspheres were blocked in a tubing connector and did not fully reach the patient and/or organ. There was no spillage or contamination of microspheres from the Y-90 dose. The tubing and catheter were placed in appropriate shielding for long term decay in storage. Below and attached are the calculations we received from the lead Nuclear Medicine technologist and Therasphere representative.' Written Directive: 68.6 mCi Administration: 64.9 mCi at 1030 [CDT] Start: 1138 [CDT] Stasis Termination: 1209 [CDT] Dose to patient: 3.6 mCi AR event number: ARK-2023-004 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 56582 +/-
Where
Jefferson Regional Medical Center Pine Bluff, Arkansas (NRC Region 4)
License number:	ARK-0623-02120
Organization:	Arkansas Department Of Health
Reporting

Agreement State
Time - Person (Reporting Time:+19.18 h0.799 days <br />0.114 weeks <br />0.0263 months <br />)
Opened:	Susan Elliott 10:41 Jun 20, 2023
NRC Officer:	Ernest West
Last Updated:	Jun 20, 2023
56582 - NRC Website
v • d • e

v t e Emergency Notification System
Jefferson Regional Medical Center with Agreement State
WEEKMONTHYEAR2023-06-19T15:30:00 [Table view]
[ENS list for Jefferson Regional Medical Center]

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ENS Notification