Event Notification Report for December 22, 2016
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
12/21/2016 - 12/22/2016
EVENT NUMBERS
52460
Agreement State
Event Number: 52460
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: REGENTS OF THE UNIVERSITY OF CALIFORNIA, LOS ANGELES
Region: 4
City: LOS ANGELES State: CA
County:
License #: 1335-19
Agreement: Y
Docket:
NRC Notified By: K. HARKNESS
HQ OPS Officer: MARK ABRAMOVITZ
Licensee: REGENTS OF THE UNIVERSITY OF CALIFORNIA, LOS ANGELES
Region: 4
City: LOS ANGELES State: CA
County:
License #: 1335-19
Agreement: Y
Docket:
NRC Notified By: K. HARKNESS
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 12/23/2016
Notification Time: 16:30 [ET]
Event Date: 12/22/2016
Event Time: 00:00 [PST]
Last Update Date: 12/23/2016
Notification Time: 16:30 [ET]
Event Date: 12/22/2016
Event Time: 00:00 [PST]
Last Update Date: 12/23/2016
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
MICHAEL HAY (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
MICHAEL HAY (R4DO)
NMSS_EVENTS_NOTIFICA (EMAI)
AGREEMENT STATE REPORT - MEDICAL UNDERSOSE
The following report was received via e-mail:
"On December 22, 2016, UCLA's alternate RSO for UCLA sent an e-mail to an RHB ICE inspector for the Radiologic Health Branch [RHB] to report a medical event, per 10 CFR 35.3045.
"A patient with metastatic sarcoma of the liver was treated by an authorized user at the medical center with Sirtex SIR-spheres containing yttrium-90 (Y-90) on December 22, 2016. A post treatment dose assessment was completed by radiation safety personnel. The authorized user prescribed 0.2 GBq (5.49 mCi) of Y-90 SIR-spheres to the left lobe of the patient's liver, but only 4.07 mCi or 74.1% was delivered. This underdose of 25.9 % caused a medical event to be reported. The patient was also treated with Y-90 SIR-spheres to the right lobe of the liver in compliance with the physician's written directive. The patient was notified by the physician and UCLA's radiation safety office is investigating the cause of the event."
California event: 122216
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 report was received via e-mail:
"On December 22, 2016, UCLA's alternate RSO for UCLA sent an e-mail to an RHB ICE inspector for the Radiologic Health Branch [RHB] to report a medical event, per 10 CFR 35.3045.
"A patient with metastatic sarcoma of the liver was treated by an authorized user at the medical center with Sirtex SIR-spheres containing yttrium-90 (Y-90) on December 22, 2016. A post treatment dose assessment was completed by radiation safety personnel. The authorized user prescribed 0.2 GBq (5.49 mCi) of Y-90 SIR-spheres to the left lobe of the patient's liver, but only 4.07 mCi or 74.1% was delivered. This underdose of 25.9 % caused a medical event to be reported. The patient was also treated with Y-90 SIR-spheres to the right lobe of the liver in compliance with the physician's written directive. The patient was notified by the physician and UCLA's radiation safety office is investigating the cause of the event."
California event: 122216
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.