ENS Event | |
|---|---|
06:00 Mar 20, 2025 | |
| Title | Agreement State REPORT- Unplanned Contamination and Medical Event |
| Event Description | The following information was provided by the Arizona Department of Health Services (the Department) via email:
On March 26, 2025, the Department received notification from the licensee about a medical event involving Y-90 (Eye90 [microspheres]) that occurred on March 20, 2025. The set up of the delivery device and administration of the Y-90 took approximately 20 minutes. During the delivery, it was noted that there were droplets on the microcatheter. While surveying personnel who were leaving the room, contamination on shoe covers and scrubs was found, which started the shutdown of the room to control [the spread of] contamination. Contamination was found on the delivery table, patient drapes, floor draping, shoe covers, and the lower part of the scrub pants of the physician. All of the contaminated items were collected, and the room was cleaned. In addition, a patient survey was performed, and the reading was significantly lower than expected. The patient was prescribed a dose of 1.72 GBq, but the licensee believes that the patient only received 30 - 55 percent of [the prescribed amount]. The Department has requested additional information and continues to investigate the event. Additional information will be provided as it is received in accordance with SA-300. AZ Event Number: 25-006 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 | |
|---|---|
| Banner Univ. Medical Center -Tucson Tucson, Arizona (NRC Region 4) | |
| License number: | 10-044 |
| Organization: | Arizona Dept Of Health Services |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+156.92 h6.538 days <br />0.934 weeks <br />0.215 months <br />) | |
| Opened: | Brian Goretzki 18:55 Mar 26, 2025 |
| NRC Officer: | Jordan Wingate |
| Last Updated: | Mar 26, 2025 |
| 57630 - NRC Website | |
Banner Univ. Medical Center -Tucson with Agreement State | |
WEEKMONTHYEARENS 576302025-03-20T06:00:00020 March 2025 06:00:00
[Table view]Agreement State Agreement State REPORT- Unplanned Contamination and Medical Event 2025-03-20T06:00:00 | |