ENS 56906

v t e ENS Event
06:00 Dec 14, 2023
Title	Safety Equipment Failure Lead to Underdose
Event Description	The following information was provided by the Louisiana Department of Environmental Quality (DEQ) via email: On December 14, 2023, the licensee was performing a Y-90 procedure. A tubing failure resulted in an incomplete dosing of the patient. All of the unadministered radiopharmaceutical was contained within the administrating device's tubing. There was no spill involved. No effect on the individual was determined. Of the prescribed dose of 105 Gy, only 50.5 Gy was administered. The remainder of the prescribed dose is scheduled to be administered on January 2, 2024. A representative from TheraSphere was in attendance during the procedure and witnessed the tube failure. The TheraSphere representative alerted their colleagues at Boston Scientific. Improvements needed to prevent recurrence: More thorough inspection of device tubing prior to administration. LA Event Report ID No.: LA20230013 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 56906 +/-
Where
St. Tammany Parish Hospital Covington, Louisiana (NRC Region 4)
License number:	LA-0569-L01, Amendment #64
Organization:	Louisiana Deq
Reporting

Agreement State
Time - Person (Reporting Time:+196.93 h8.205 days <br />1.172 weeks <br />0.27 months <br />)
Opened:	James Pate 10:56 Dec 22, 2023
NRC Officer:	Bethany Cecere
Last Updated:	Dec 26, 2023
56906 - NRC Website
v • d • e

v t e Emergency Notification System
St. Tammany Parish Hospital with Agreement State
WEEKMONTHYEAR2023-12-14T06:00:00 [Table view]
[ENS list for St. Tammany Parish Hospital]

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