ENS 54840: Difference between revisions
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{{ENS notification | {{ENS notification | ||
| event number = 54840 | | event number = 54840 | ||
| facility = | | facility = | ||
| Organization = Ohio Department Of Health | | Organization = Ohio Department Of Health | ||
| license number = OH-02120250070 | | license number = OH-02120250070 | ||
| Line 10: | Line 10: | ||
| utype = | | utype = | ||
| cfr = Agreement State | | cfr = Agreement State | ||
| emergency class = | | emergency class = Non Emergency | ||
| notification date = 08/18/2020 13:13 | | notification date = 08/18/2020 13:13 | ||
| notification by = Michael Rubadue | | notification by = Michael Rubadue | ||
| Line 19: | Line 19: | ||
| event text = The following report was received from the Ohio Department of Health via email. | | event text = The following report was received from the Ohio Department of Health via email. | ||
On August 14, 2020, the licensee attempted to treat a patient with Y-90 TheraSphere microspheres. Under the guidance of the manufacturer's representative, the AU [Authorized User] performed pre-patient checks on the device, including tubing patency check. After the infusion was started it became apparent the patient was not receiving the dose, and the licensee was unable to clear the blockage in the tubing. The procedure was terminated and the patient and referring physician were notified. Approximately 93% of the activity remained in the device. Static imaging was performed on the patient to determine the dose received. There was no measurable activity in the patient. | On August 14, 2020, the licensee attempted to treat a patient with Y-90 TheraSphere microspheres. Under the guidance of the manufacturer's representative, the AU [Authorized User] performed pre-patient checks on the device, including tubing patency check. After the infusion was started it became apparent the patient was not receiving the dose, and the licensee was unable to clear the blockage in the tubing. The procedure was terminated and the patient and referring physician were notified. Approximately 93% of the activity remained in the device. Static imaging was performed on the patient to determine the dose received. There was no measurable activity in the patient. | ||
Ohio Event No.: | Ohio Event No.: OH200004 | ||
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/2020/20200826en.html#en54840 | ||
}} | }} | ||
{{ENS-Nav}} | {{ENS-Nav}} | ||
Latest revision as of 12:24, 15 January 2021
| Where | |
|---|---|
| Ohio Department Of Health Columbus, Ohio (NRC Region 3) | |
| License number: | OH-02120250070 |
| Organization: | Ohio Department Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+9.22 h0.384 days <br />0.0549 weeks <br />0.0126 months <br />) | |
| Opened: | Michael Rubadue 13:13 Aug 18, 2020 |
| NRC Officer: | Michael Bloodgood |
| Last Updated: | Aug 18, 2020 |
| 54840 - NRC Website | |