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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 56926 | 12 January 2024 06:00:00 | Agreement State | Y-90 Incomplete Dose | The following information was provided by the Louisiana Department of Environmental Quality (LA DEQ) via email: This medical event was reported (to the LA DEQ) on January 13, 2024, at 2259 (CST). On January 12, 2024, the licensee was performing a Y-90 brachytherapy medical procedure. A tubing failure (catheter) resulted in an incomplete dosing of the patient. The catheter became blocked up with the undelivered radiopharmaceutical Y-90. The Y-90 was contained within the administrating device's tubing. There was no spill involved. The Y-90 being used was TheraSphere from Boston Scientific. Approximately 23 percent of the radiopharmaceutical Y-90 was delivered to the patient. No effect on the individual was determined. The remainder of the prescribed dose will be administered to the patient at a later date. LA DEQ Event Report ID: LA20240001 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 53785 | 7 December 2018 06:00:00 | Agreement State | Agreement State Report - Potential Overexposure | The following information was received from the State of Louisiana via email: (On 12/7/2018, the licensee's RSO reported to the Louisiana Department of Environmental Quality (LDEQ)) that his personnel monitoring provider had informed him of excessive exposures to a Nuclear Medicine Technologist's (NMT) monitors. The monitors had received a whole-body exposure of 6,358 mRem and an extremity exposure 29,245 mRem. The monitoring period was 9/20/20018 to 10/19/2018. (The RSO's) in-house investigation revealed he had a 'Reportable NMED Event'. The event occurred under the Ochsner Clinic Foundation Broad Scope Medical License (OCFBS), LA-0002-L01. The event involves two monitors, a whole-body and an extremity monitor. The monitoring company could not determine the type of exposure using their normal exposure filters. The RSO for this licensee did his own investigation after he was notified of the exposures on 12/5/2018. The RSO interviewed the NMT, reviewed area survey records, and did a bioassay of the NMT. The isotopes in use at the facility are Tc-99, Lu-177, and a Ga-68 generator. The NMT attaches both monitors together for storage after their use. The NMT did admit to not being in gloves at all times when handling radioactive isotopes. The RSO called in the possible NMED event (to the LDEQ) when he finished his investigation on 12/7/2018. This incident is being reported as a (potential) real or threatened excessive exposure NMED Event on 12/10/2018. The actual exposure determination will be up-dated when LDEQ concludes its investigation. LDEQ considers this incident still open and subject to investigation and corrective action implementation. Event Report ID No.: LA-180020 |