Event Notification Report for March 20, 2025
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
03/19/2025 - 03/20/2025
EVENT NUMBERS
57630
57630
Agreement State
Event Number: 57630
Rep Org: Arizona Dept of Health Services
Licensee: Banner Univ. Medical Center -Tucson
Region: 4
City: Tucson State: AZ
County: Pima
License #: 10-044
Agreement: Y
Docket:
NRC Notified By: Brian Goretzki
HQ OPS Officer: Jordan Wingate
Licensee: Banner Univ. Medical Center -Tucson
Region: 4
City: Tucson State: AZ
County: Pima
License #: 10-044
Agreement: Y
Docket:
NRC Notified By: Brian Goretzki
HQ OPS Officer: Jordan Wingate
Notification Date: 03/26/2025
Notification Time: 18:55 [ET]
Event Date: 03/20/2025
Event Time: 00:00 [MDT]
Last Update Date: 03/26/2025
Notification Time: 18:55 [ET]
Event Date: 03/20/2025
Event Time: 00:00 [MDT]
Last Update Date: 03/26/2025
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Deese, Rick (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Silberfeld, Dafna (NMSS)
Deese, Rick (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Silberfeld, Dafna (NMSS)
AGREEMENT STATE REPORT- UNPLANNED CONTAMINATION AND MEDICAL EVENT
The following information was provided by the Arizona Department of Health Services (the Department) via email:
"On March 26, 2025, the Department received notification from the licensee about a medical event involving Y-90 (Eye90 [microspheres]) that occurred on March 20, 2025. The set up of the delivery device and administration of the Y-90 took approximately 20 minutes. During the delivery, it was noted that there were droplets on the microcatheter. While surveying personnel who were leaving the room, contamination on shoe covers and scrubs was found, which started the shutdown of the room to control [the spread of] contamination. Contamination was found on the delivery table, patient drapes, floor draping, shoe covers, and the lower part of the scrub pants of the physician. All of the contaminated items were collected, and the room was cleaned. In addition, a patient survey was performed, and the reading was significantly lower than expected. The patient was prescribed a dose of 1.72 GBq, but the licensee believes that the patient only received 30 - 55 percent of [the prescribed amount]. The Department has requested additional information and continues to investigate the event.
"Additional information will be provided as it is received in accordance with SA-300."
AZ Event Number: 25-006
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.
The following information was provided by the Arizona Department of Health Services (the Department) via email:
"On March 26, 2025, the Department received notification from the licensee about a medical event involving Y-90 (Eye90 [microspheres]) that occurred on March 20, 2025. The set up of the delivery device and administration of the Y-90 took approximately 20 minutes. During the delivery, it was noted that there were droplets on the microcatheter. While surveying personnel who were leaving the room, contamination on shoe covers and scrubs was found, which started the shutdown of the room to control [the spread of] contamination. Contamination was found on the delivery table, patient drapes, floor draping, shoe covers, and the lower part of the scrub pants of the physician. All of the contaminated items were collected, and the room was cleaned. In addition, a patient survey was performed, and the reading was significantly lower than expected. The patient was prescribed a dose of 1.72 GBq, but the licensee believes that the patient only received 30 - 55 percent of [the prescribed amount]. The Department has requested additional information and continues to investigate the event.
"Additional information will be provided as it is received in accordance with SA-300."
AZ Event Number: 25-006
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.