ENS 56596

v t e ENS Event
05:00 Jun 28, 2023
Title	Medical Event - Patient Underdose
Event Description	The following information was provided by the Veterans Health Administration (VHA) National Health Physics Program (NHPP) via phone and email: On June 28, 2023, the VHA NHPP was notified of a medical event at the Michael E. DeBakey VA Medical Center, Houston, Texas. The medical center holds VHA permit number 42-00084-06. The medical event occurred on June 28, 2023. The event involved the intra-arterial administration of two vials of yttrium-90 (Y-90) microspheres to the liver of a patient. Measurements taken after the procedure of one of the vials, the administration set, and catheter showed an unusually large amount of activity remaining that had not been delivered to the patient. From the measurements, it was estimated that only 28 percent of the prescribed activity for that vial was delivered to the patient. The activity delivered from the other vial was within regulatory requirements. The causes are not certain at this time; the event is under investigation. The patient has been notified. NHPP plans to conduct a reactive inspection regarding the event. NHPP will send a written report to NRC Region III in accordance with 10 CFR 35.3045. NHPP has notified the NRC Project Manager for the Master Materials License of NRC Region III. 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 56596 +/-
Where
Michael E. Debakey Va Medical Center Little Rock, Arkansas (NRC Region 3)
License number:	03-23853-01VA
Organization:	Va National Health Physics Program
Reporting

10 CFR 35.3045(a)(1)
Time - Person (Reporting Time:+33.62 h1.401 days <br />0.2 weeks <br />0.0461 months <br />)
Opened:	Joseph Bravenec 14:37 Jun 29, 2023
NRC Officer:	Ernest West
Last Updated:	Jun 29, 2023
56596 - NRC Website
v • d • e

v t e Emergency Notification System
Michael E. Debakey Va Medical Center with 10 CFR 35.3045(a)(1)
WEEKMONTHYEAR2023-06-28T05:00:00 [Table view]
[ENS list for Michael E. Debakey Va Medical Center]

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