Event Notification Report for February 06, 2024
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
02/05/2024 - 02/06/2024
Agreement State
Event Number: 56940
Rep Org: California Radiation Control Prgm
Licensee: Cedars Sinai Medical Center
Region: 4
City: Los Angeles State: CA
County:
License #: 0404-19
Agreement: Y
Docket:
NRC Notified By: L. Robert Greger
HQ OPS Officer: Natalie Starfish
Notification Date: 01/30/2024
Notification Time: 19:48 [ET]
Event Date: 01/30/2024
Event Time: 14:50 [PST]
Last Update Date: 01/30/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Agrawal, Ami (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE - Y-90 UNDERDOSE
The following is a summary of information that was provided by the California Department of Public Health, Radiological Health Branch via email:
On January 30, 2024, at 1450 PST, the radiation safety officer of Cedars Sinai Medical Center contacted the Los Angeles County Radiation Management office to report a medical underdose event. The underdose occurred during a treatment of Y-90 (yttrium-90) TheraSpheres microspheres for a radioembolization treatment for liver cancer. The prescribed activity was 480 Gy and the administered activity was 227.6 Gy (about 47 percent of the prescription). The underdose was due to an obstruction of the microcatheter used to deliver the Y-90. The patient has been notified.
Cedars Sinai Medical Center will conduct an investigation to gain a better understanding of the details of the event.
CA event ID number: 013024
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.