ENS 54684: Difference between revisions

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{{ENS notification
{{ENS notification
| event number = 54684
| event number = 54684
| facility = Piedmont Hospital
| facility =  
| Organization = Georgia Radioactive Material Pgm
| Organization = Florida Bureau Of Radiation Control
| license number = GA 292-1
| license number = N/A
| region = 1
| region = 1
| state = Georgia
| state = Florida
| city = Atlanta
| city = Jacksonville
| unit =  
| unit =  
| utype =  
| utype =  
| cfr = Agreement State
| cfr = Agreement State
| emergency class = Non Emergency  
| emergency class = Non Emergency
| notification date = 04/29/2020 16:16
| notification date = 04/30/2020 15:37
| notification by = Irene Bennett
| notification by = Matthew Senison
| NRC officer = Howie Crouch
| NRC officer = Howie Crouch
| event date = 05/28/2019 00:00 EDT
| event date = 04/20/2020 00:00 EDT
| last update date = 04/29/2020
| last update date = 04/30/2020
| title = Agreement State Report - Delivered Dose of Yttrium-90 Theraspheres Differed from Prescribed Dose by Greater than 20 Percent
| title = Agreement State Report - Used Beverage Can (Ubc) Baled Aluminum Returned to Florida
| event text = The following information was received from the state of Georgia via email:
| event text = The following information was received from the state of Florida via email:
On May 28, 2019, it was brought to [Piedmont Hospital's radiation safety officer (RSO)] attention that a Y-90 TheraSphere administration had not delivered the full prescribed activity to the patient as intended. Upon further discussion, it was noted that the performing physician noticed, after connection of the line between the microcatheter and the delivery vial, that multiple air bubbles had become trapped in the line. He then created a closed system manifold using a three-way stopcock and syringes to effectively bleed out air bubbles and flush back as much of the dose as possible to the patient. The closed system prevented any spillage or contamination and residual dose was retained in the syringes and stopcocks. Despite these actions taken by [the performing physician], a post-administration assay of the waste container showed that the full desired activity had not made it out of the delivery equipment and into the patient. The procedure was a segmentectomy, and the patient will be re-evaluated in one month's time to determine if an additional therapeutic administration will be needed.
The state of Kentucky Radiation Health [Branch] faxed a report of rejection of an UBC [used beverage can) bale from Logan Aluminum of KY, originating from Republic Services of Jacksonville, FL. The radiation measurement was 1200 cps (also reported as 0.7 mR/hr.) midway of the enclosed trailer. Background measured 121 cps.
The prescribed activity to be delivered to the patient was 2.15 GBq (58 mCi). The calculated delivered activity to the patient was 1.01 GBq (27.3 mCi). Delivered activity was determined by comparing pre- and post-administration survey meter measurements of the administration equipment, as per standard TheraSphere procedure.
DOT-SP 10656 KY-FL-20-001 was issued. Per [an employee] of Republic Services, this load was comprised of household curbside waste, and 'people put whatever they want in there.' Only one bale was higher than background. The rest of load successfully resubmitted.
Root Cause - Human error: Air was likely trapped somewhere in the system during the initial setup of the equipment. Operator technique failed to completely purge the lines of this air. Air bubbles in the line were not visible or not noticed prior to the connection of the line. Efforts to eliminate the air and deliver the full dose to the patient were then not successful.
Update: This bale was returned to Florida for investigation, whereupon [the Radiation Safety Officer at Republic Services] reached out to the [Headquarters Operations Officer at the Nuclear Regulatory Commission], who transferred him to the BRC [Florida Bureau of Radiation Control].
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.
Florida BRC will be conducting a follow-up investigation.
| URL = https://www.nrc.gov/reading-rm/doc-collections/event-status/event/2020/20200507en.html#en54684
Florida Incident Number: FL20-051
| URL = https://www.nrc.gov/reading-rm/doc-collections/event-status/event/2020/20200511en.html#en54684
}}
}}


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Latest revision as of 12:39, 15 January 2021

ENS 54684 +/-
Where
Florida Bureau Of Radiation Control
Jacksonville, Florida (NRC Region 1)
License number: N/A
Organization: Florida Bureau Of Radiation Control
Reporting
Agreement State
Time - Person (Reporting Time:+251.62 h10.484 days <br />1.498 weeks <br />0.345 months <br />)
Opened: Matthew Senison
15:37 Apr 30, 2020
NRC Officer: Howie Crouch
Last Updated: Apr 30, 2020
54684 - NRC Website
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