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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 50814 | 10 February 2015 05:00:00 | Agreement State | Agreement State Report - Medical Event Involving the Administration of Y-90 Microspheres | The following information was obtained from the Commonwealth of Pennsylvania via facsimile: Notifications: The Department (Pennsylvania Department of Environmental Protection) was notified of this event on Wednesday, February 11, 2015. It is immediately reportable as per 10 CFR 35.3045(a)(1)(i). Event Description: A patient was receiving Y-90 Sirtex Sirspheres when the administering device failed and a portion of the dose was lost in the apparatus. The patient received 10.4 mCi, or 58% of the prescribed 17.82 mCi dose. Cause of the event: The device came apart during the procedure and the remainder of the dose was contained in the packaging. Actions: The Department plans a reactive inspection. Pennsylvania Event Report ID No: PA150004 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 51774 | 2 March 2016 05:00:00 | Agreement State | Agreement State Report - Contamination Event with Possible Shallow Dose Exceeding Federal Limits | The following report was received from the Commonwealth of Pennsylvania via facsimile: Notifications: The event occurred on March 2, 2016, the licensee discovered the event on March 3, 2016, and notified the Department (Pennsylvania Department of Environmental Protection) on March 4, 2016, via a phone call. The event is reportable per 10 CFR 30.50(b)(1)(i) and 10 CFR 20.2202(b)(1)(iii). Event Description: On March 2, 2016, a technologist was injecting a samarium-153 'Quadramet' dose (approximately 81 milliCuries) when there was a problem with the syringe/tubing connection. A 'blowback' occurred and a small amount, believed to be approximately 1-2 mCi, of the dose spilled. The patient was released (and sent) home. The technologist stated that he had gloves on, washed his hands, surveyed the area and called the lead technologist to notify her of the incident. Radiation Safety (at the hospital) was not notified until March 3rd. The technologist was surveyed and found to have contamination on his hands and forearms. An initial calculation indicated a skin dose above 50 rem. Radiation Safety then took smears throughout the department and contamination was found on various surfaces including the floor, other technologist's hands, gloves, shoes, survey meters, chairs, and clothing. Removable contamination was also found in a technologist's vehicle. Radiation Safety has decontaminated most areas. Surfaces and rooms that were not able to be decontaminated were closed off (for decay) or covered with paper to prevent any further spread of contamination. It is believed that after the spill, the technologist attempted to clean up the area. Apparently it was not sufficient, for when housekeeping did their routine cleaning, they may have unknowingly further spread the contamination with floor mopping and other cleaning. No biological effects are expected with any individual. The RSO (Radiation Safety Officer) feels that a 'medical event' did not occur with the patient. The patient returned for a scheduled scan on March 3rd, and that scan appeared normal. The patient did not show any signs of detectable contamination on her skin. Cause of the Event: Human error. The technologist may not have followed proper procedures, and contributed to the contamination spreading beyond initial spill area. Actions: A reactive inspection is planned by the Department (Pennsylvania Department of Environmental Protection). More information will be provided upon receipt. Event Report ID No: PA160008 |