ENS Event | |
|---|---|
13:24 Feb 13, 2019 | |
| Title | Agreement State Report - Dose Delivered Was Less than Prescribed |
| Event Description | The following was received from the Arkansas Department of Health, Radiation Control Program (the Department) via email:
The treatment prescribed activity was for 0.54 GBq (14.5 mCi) on February 13, 2019. The calibrated activity at projected treatment time was 0.53 GBq (14.3 mCi). The patient received a dose of 0.204 GBq (5.51 mCi) due to 61.5 percent of the dose remaining in the connector of the manufacturer tubing and the catheter Terumo-Progreat Microcatheter (2.0 French Catheter). The Department performed an on-site review and investigation on February 15, 2019 at approximately 1215 [CST]. The Department performed exposure surveys of the connector confirming activity stuck at the connector site. The connector site read the highest and in that concentrated area, reading 430 mR/hr, on February 15, 2019, at approximately 1415 [CST]. There were no spills and/or contamination during this event. The licensee notified the manufacturer and the manufacturer will be performing an investigation on the tubing and radiopharmaceutical/sealed sources. The licensee is continuing to investigate the root cause and is preparing an initial fifteen day written report. The Department is waiting on information from the manufacturer(s) and licensee for further investigation. The Department will update this report when the licensee provides additional information. Arkansas Event AR-2019-001 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. |
| Where | |
|---|---|
| University Of Arkansas For Medical Sciences Little Rock, Arkansas (NRC Region 4) | |
| License number: | ARK-0001-02110 |
| Organization: | Arkansas Department Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+51.72 h2.155 days <br />0.308 weeks <br />0.0708 months <br />) | |
| Opened: | Angie Hall 17:07 Feb 15, 2019 |
| NRC Officer: | Thomas Kendzia |
| Last Updated: | Feb 15, 2019 |
| 53879 - NRC Website | |
University Of Arkansas For Medical Sciences with Agreement State | |
WEEKMONTHYEARENS 571782024-06-07T05:00:0007 June 2024 05:00:00
[Table view]Agreement State Y-90 Microsphere Underdose ENS 538792019-02-13T13:24:00013 February 2019 13:24:00 Agreement State En Revision Imported Date 6/5/2019 ENS 511302015-06-04T05:00:0004 June 2015 05:00:00 Agreement State Agreement State Report - Medical Treatment Incorrect Dose ENS 467182011-03-16T05:00:00016 March 2011 05:00:00 Agreement State Agreement State Report - Yttrium-90 Microspsheres Administered Dose Less than Prescribed Dose 2024-06-07T05:00:00 | |