ENS Event | |
|---|---|
06:00 Dec 14, 2023 | |
| Title | |
| Event Description | The following information was provided by the Louisiana Department of Environmental Quality (DEQ) via email:
On December 14, 2023, the licensee was performing a Y-90 procedure. A tubing failure resulted in an incomplete dosing of the patient. All of the unadministered radiopharmaceutical was contained within the administrating device's tubing. There was no spill involved. No effect on the individual was determined. Of the prescribed dose of 105 Gy, only 50.5 Gy was administered. The remainder of the prescribed dose is scheduled to be administered on January 2, 2024. A representative from TheraSphere was in attendance during the procedure and witnessed the tube failure. The TheraSphere representative alerted their colleagues at Boston Scientific. Improvements needed to prevent recurrence: More thorough inspection of device tubing prior to administration. LA Event Report ID No.: LA20230013 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 | |
|---|---|
| St. Tammany Parish Hospital Covington, Louisiana (NRC Region 4) | |
| License number: | LA-0569-L01, Amendment #64 |
| Organization: | Louisiana Deq |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+196.93 h8.205 days <br />1.172 weeks <br />0.27 months <br />) | |
| Opened: | James Pate 10:56 Dec 22, 2023 |
| NRC Officer: | Bethany Cecere |
| Last Updated: | Dec 26, 2023 |
| 56906 - NRC Website | |
St. Tammany Parish Hospital with Agreement State | |
WEEKMONTHYEARENS 569062023-12-14T06:00:00014 December 2023 06:00:00
[Table view]Agreement State Safety Equipment Failure Lead to Underdose ENS 554892021-09-23T21:00:00023 September 2021 21:00:00 Agreement State Underdose of Y-90 Theraspheres 2023-12-14T06:00:00 | |