ENS 54967
ENS Event | |
|---|---|
04:00 Oct 23, 2020 | |
| Title | Dose Delivered Differs by Greater than 20 Percent |
| Event Description | The following was received from the Georgia Radioactive Materials Program (the Program) via email:
The Y-90 event [occurred] on October 23, 2020. The AU [(Authorized User)] notified the Assistant RSO [(Radiation Safety Officer)] on October 26 and then subsequently notified our Program on October 27, 2020. The reason for the delay notifying the Program was both the Radiation Safety Officer (RSO) and Assistant Radiation Safety Officer (ARSO) were furloughed on Friday [(October 23)] and they did not check their emails until Monday. They used Monday to gather information before contacting the State Program. The patient was administered with 1.58 GBq using a 10 mL syringe. The reason for the 10 mL syringe was a small gauge catheter was used. The line was subsequently flushed 3 times with saline solution to ensure the Y-90 was pushed through. After the procedure, the catheter was removed and surveyed along with the vial to determine residual activity. It was calculated that there was more residual [activity] than expected. Though it is has not been clearly determined the cause of the excess residual [activity], it is thought to be either not enough saline was used to push the Y-90 through or it got stuck in the catheter. The ARSO and the Authorized User will discuss the cause of the event, best way to prevent occurrence, and [perform] patient follow-up. The licensee will follow-up with a report within 15 days. In the interim, the licensee is required to submit a copy of the written directive, Y-90 procedure and checklist, and the rational why they used a small catheter gauge. The actual dose delivered was 1.039 GBq (65.5 percent). Georgia Incident No: 31 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 | |
|---|---|
| Emory University Atlanta, Georgia (NRC Region 1) | |
| License number: | GA 153-1 |
| Organization: | Georgia Radioactive Material Pgm |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+109.83 h4.576 days <br />0.654 weeks <br />0.15 months <br />) | |
| Opened: | Irene Bennett 17:50 Oct 27, 2020 |
| NRC Officer: | Ossy Font |
| Last Updated: | Oct 27, 2020 |
| 54967 - NRC Website | |
Emory University with Agreement State | |
WEEKMONTHYEARENS 569462024-02-01T05:00:0001 February 2024 05:00:00
[Table view]Agreement State Lost Source ENS 560072022-07-20T04:00:00020 July 2022 04:00:00 Agreement State Dose Misadministration ENS 558502022-04-11T04:00:00011 April 2022 04:00:00 Agreement State Lost/Missing Source ENS 549742020-10-29T04:00:00029 October 2020 04:00:00 Agreement State Dose Delivered Differs by Greater than 20 Percent ENS 549672020-10-23T04:00:00023 October 2020 04:00:00 Agreement State Dose Delivered Differs by Greater than 20 Percent ENS 534682018-06-21T04:00:00021 June 2018 04:00:00 Agreement State En Revision Imported Date 7/3/2018 ENS 529792017-08-24T04:00:00024 August 2017 04:00:00 Agreement State Agreement State Report - Dose Delivered 20% Greater than Prescribed and Greater than 50 Rem to the Targeted Area ENS 499172014-02-27T04:00:00027 February 2014 04:00:00 Agreement State Agreement State Report - Yttrium 90 Medical Event ENS 484412011-05-24T04:00:00024 May 2011 04:00:00 Agreement State Agreement State Report - Y-90 Therasphere Spill ENS 452462009-08-05T04:00:0005 August 2009 04:00:00 Agreement State Agreement State Report - Medical Dose Different than Prescribed ENS 443312008-05-31T04:00:00031 May 2008 04:00:00 Agreement State Agreement State - Possible Overexposure 2024-02-01T05:00:00 | |