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| Entered date | Event description | |
|---|---|---|
| ENS 49711 | 10 January 2014 09:45:00 | On January 10, 2014, the Agency received a report from the licensee's Radiation Safety Officer (RSO) stating the shutter on a Ohmart Vega model SGLG gauge containing a 500 millicurie cesium - 137 source was found stuck in the open position. Open is the normal operation position of the gauge shutter. The RSO stated a contractor was performing a calibration of a level detector on January 9, 2014, when they could not get the gauge shutter to close. The contractor sprayed the shutter with a light oil and attempted to rotate the handle and operating arm. While trying to free the shutter, the operating arm separated from the gauge. The contractor was able to insert the operating rod into the gauge, but the shutter would not move. The manufacturer has been contacted to assist in the repair or replacement of the gauge. No exposure resulted from this event and the current position of the gauge shutter does not create any additional exposure risk to any personnel. A contact dose rate survey of the gauge was conducted and the highest reading observed was 1.2 millirem per hour. Additional information will be provided as it is received in accordance with SA-300. Texas Incident Number: I-9145 |
| ENS 53972 | 3 April 2019 13:40:00 | The following was received from the State of Kentucky via fax. On Thursday, March 21, 2019, a technologist inadvertently used Ringer's saline as the eluate on a Bracco Rb-82 generator. On March 21, 2019, four (4) patients were imaged using the Rb-82 generator at 0852/0902, 1037/1049, 1143/1156, and 1335/1347 EDT (two infusions per patient). On March 21, 2019, a technologist notified Bracco that their eluate volumes for each patient were decreasing slightly, while the overall activity of each infusion remained the same, this was the inverse of what they normally saw. On the morning of March 22, 2019, routine quality control was performed at 0730 EDT and it was found that the Sr-82 breakthrough measured 18.6 microCuries and the generator expiry limit was exceeded. The technologist inspected the unit's tubing and settings, but found nothing out of the ordinary. The Bracco representative returned the previous day's call and said to check the saline attached to the machine. It was discovered that Ringer's saline had been used. The RSO (Radiation Safety Officer) was notified and the hospital was instructed to discontinue use. Kentucky Event Report ID No.: KY190003 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 55557 | 3 November 2021 12:08:00 | The following information was received from the Commonwealth of Massachusetts via email: On November 2, 2021, 3:00 PM (EDT), licensee reported medical event under license 60-0160 for Sirtex Wilmington LLC SIR-Spheres Y-90 microspheres (SS&D MA-1229-D-101-S) emerging technology for total administered activity that differed from prescribed treatment activity as documented in the written directive by 20 percent or more. A portion of a Y-90 5 mCi microsphere therapy treatment delivered to patient liver on November 2, 2021 remained in the delivery system causing delivery of approximately 3.67 mCi Y-90 of the prescribed 5 mCi. The error was discovered immediately after treatment. Administered dose to treatment area differed from prescribed dose by approximately 27 percent. Licensee stated the cause, including possible equipment malfunction, has not yet been determined. Prescribing physician, referring physician and patient have been notified. Licensee stated no negative health effects to patient due to situation. No additional Y-90 therapy treatment would be required due to this situation. Licensee stated all Y-90 was accounted for. Licensee stated 5 mCi prescription was unusually small compared to previous procedures (range 9-to-39 mCi with 15 mCi being the most prescribed dose). Licensee to submit written report within 15 days of discovery date. This is a next day reportable medical event per regulation. Investigation ongoing. Agency considers this event docket to still be OPEN. Report by Anthony Carpenito, 11/3/2021. |