Event Notification Report for July 08, 2020
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
07/07/2020 - 07/08/2020
EVENT NUMBERS
54775
Agreement State
Event Number: 54775
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: Regents of the Univeristy of California, Los Angeles
Region: 4
City: Los Angeles State: CA
County:
License #: 1335-19
Agreement: Y
Docket:
NRC Notified By: Andrew Taylor
HQ OPS Officer: Solomon Sahle
Licensee: Regents of the Univeristy of California, Los Angeles
Region: 4
City: Los Angeles State: CA
County:
License #: 1335-19
Agreement: Y
Docket:
NRC Notified By: Andrew Taylor
HQ OPS Officer: Solomon Sahle
Notification Date: 07/10/2020
Notification Time: 20:18 [ET]
Event Date: 07/08/2020
Event Time: 00:00 [PDT]
Last Update Date: 07/10/2020
Notification Time: 20:18 [ET]
Event Date: 07/08/2020
Event Time: 00:00 [PDT]
Last Update Date: 07/10/2020
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
VINCENT GADDY (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
GRETCHEN RIVERA-CAPELLA (NMSS DAY)
VINCENT GADDY (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
GRETCHEN RIVERA-CAPELLA (NMSS DAY)
AGREEMENT STATE REPORT - MEDICAL EVENT
The following report was received from the State of California via email:
"On July 10, 2020, the Radiation Safety Officer for the University of California, Los Angeles, notified the Radiologic Health Branch of a Medical Event that occurred with a Varian High Dose Afterloader with an Ir-192 source during an ovarian cancer treatment. The prescribed dose to the intended organ was 24 Gray (2400 rad). Due to an incorrect entry of the catheter length into the treatment delivery system, an unintended dose of 21.8 Gray (2180 rad) was estimated to have been delivered to the large bowel. The dose delivered to the intended organ was initially estimated at 0 Gray (0 rad). The patient and the patient's physician were notified. The licensee's investigation into this medical event is ongoing and will be reviewed further by the California Department of Public Health"
California 5010 report no: 071020
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 from the State of California via email:
"On July 10, 2020, the Radiation Safety Officer for the University of California, Los Angeles, notified the Radiologic Health Branch of a Medical Event that occurred with a Varian High Dose Afterloader with an Ir-192 source during an ovarian cancer treatment. The prescribed dose to the intended organ was 24 Gray (2400 rad). Due to an incorrect entry of the catheter length into the treatment delivery system, an unintended dose of 21.8 Gray (2180 rad) was estimated to have been delivered to the large bowel. The dose delivered to the intended organ was initially estimated at 0 Gray (0 rad). The patient and the patient's physician were notified. The licensee's investigation into this medical event is ongoing and will be reviewed further by the California Department of Public Health"
California 5010 report no: 071020
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.