ENS 54882: Difference between revisions
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{{ENS notification | {{ENS notification | ||
| event number = 54882 | | event number = 54882 | ||
| facility = | | facility = | ||
| Organization = Georgia Radioactive Material Pgm | | Organization = Georgia Radioactive Material Pgm | ||
| license number = GA 1632-1 | | license number = GA 1632-1 | ||
| Line 10: | Line 10: | ||
| utype = | | utype = | ||
| cfr = Agreement State | | cfr = Agreement State | ||
| emergency class = | | emergency class = Non Emergency | ||
| notification date = 09/04/2020 15:01 | | notification date = 09/04/2020 15:01 | ||
| notification by = Irene Bennett | | notification by = Irene Bennett | ||
| Line 16: | Line 16: | ||
| event date = 09/02/2020 00:00 EDT | | event date = 09/02/2020 00:00 EDT | ||
| last update date = 09/04/2020 | | last update date = 09/04/2020 | ||
| title = Agreement State Report - Medical Event - Underdose | | title = <Td Align="Left" Scope="Row">Agreement State Report - Medical Event - Underdose | ||
| event text = The following was received from the Georgia Radioactive Materials Program via email: | | event text = The following was received from the Georgia Radioactive Materials Program via email: | ||
At the end of the administration of Y-90 SIR Spheres [for the treatment of tumors in the right lobe of the liver], the delivery vial (D-Vial) appeared to overfill as the radiologist was attempting to mix the spheres with a 50/50 solution of contrast and 5 percent dextrose/glucose (D5W). The radiologist noticed some clumping and after attempting to gently disperse the Spheres, he gave a couple hard pushes of the contrast/D5W into the D-Vial. At that time, he noticed the leak. He examined the septum and found it to be dry. As a precaution the radiologist put Durabond on top of the septum. Further examination showed that the material leaked out of the sides of the crimped vial top rather than the septum. The procedure was stopped to prevent further contamination. | At the end of the administration of Y-90 SIR Spheres [for the treatment of tumors in the right lobe of the liver], the delivery vial (D-Vial) appeared to overfill as the radiologist was attempting to mix the spheres with a 50/50 solution of contrast and 5 percent dextrose/glucose (D5W). The radiologist noticed some clumping and after attempting to gently disperse the Spheres, he gave a couple hard pushes of the contrast/D5W into the D-Vial. At that time, he noticed the leak. He examined the septum and found it to be dry. As a precaution the radiologist put Durabond on top of the septum. Further examination showed that the material leaked out of the sides of the crimped vial top rather than the septum. The procedure was stopped to prevent further contamination. | ||
| Line 26: | Line 26: | ||
Further evaluation of the equipment to determine why the vial leaked, will be performed following decay and return the manufacturer. | Further evaluation of the equipment to determine why the vial leaked, will be performed following decay and return the manufacturer. | ||
Georgia Incident Number: 30 | Georgia Incident Number: 30 | ||
A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. | 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. | ||
| URL = https://www.nrc.gov/reading-rm/doc-collections/event-status/event/2020/ | | URL = https://www.nrc.gov/reading-rm/doc-collections/event-status/event/2020/20200915en.html#en54882 | ||
}} | }} | ||
{{ENS-Nav}} | {{ENS-Nav}} | ||
Latest revision as of 12:20, 15 January 2021
| Where | |
|---|---|
| Georgia Radioactive Material Pgm Newman, Georgia (NRC Region 1) | |
| License number: | GA 1632-1 |
| Organization: | Georgia Radioactive Material Pgm |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+59.02 h2.459 days <br />0.351 weeks <br />0.0808 months <br />) | |
| Opened: | Irene Bennett 15:01 Sep 4, 2020 |
| NRC Officer: | Jeffrey Whited |
| Last Updated: | Sep 4, 2020 |
| 54882 - NRC Website | |