Event Notification Report for October 29, 2026
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
10/28/2026 - 10/29/2026
Agreement State
Event Number: 58495
Rep Org: Oregon Radiation Protection Services
Licensee: Peace Health Sacred Heart Medical Ctr
Region: 4
City: Springfield State: OR
County:
License #: 90270
Agreement: Y
Docket:
NRC Notified By: Thomas Mynes
HQ OPS Officer: Christopher Prescott
Licensee: Peace Health Sacred Heart Medical Ctr
Region: 4
City: Springfield State: OR
County:
License #: 90270
Agreement: Y
Docket:
NRC Notified By: Thomas Mynes
HQ OPS Officer: Christopher Prescott
Notification Date: 10/14/2026
Notification Time: 13:31 [ET]
Event Date: 10/13/2026
Event Time: 00:00 [PDT]
Last Update Date: 10/28/2026
Notification Time: 13:31 [ET]
Event Date: 10/13/2026
Event Time: 00:00 [PDT]
Last Update Date: 10/28/2026
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
NMSS_EVENTS_NOTIFICATION (EMAIL)
Logan Allen (NMSS)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Logan Allen (NMSS)
EN Revision Imported Date: 10/29/2026
EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT
The following is a summary of information provided by the Oregon Health Authority's Radiation Protection Services (RPS) via phone and email:
On October 13, 2026, RPS was notified by the licensee of activity delivered outside the intended target during a Y-90 microsphere treatment for liver cancer.
The written directive prescribed administration of 5.67 GBq to the right lobe of the liver for a target dose of 120 Gy. The licensee estimated the delivered dose to be approximately 123 Gy.
A post-treatment Bremsstrahlung scan indicated that delivery was segmental to the caudate lobe of the liver and surrounding tissue. Two SPEC-CT scans were performed and revealed delivery near the gallbladder fossa (patient does not have a gallbladder). The authorized user determined that activity was delivered outside the intended area, with some in the liver and some in the tissue or ductal interworking around the liver.
The patient was informed of the findings. A written report, containing all information required under 10 CFR 35.3045(d), will be submitted within 15 days of discovery.
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.
* * * UPDATE ON 10/28/2026 AT 1419 EDT FROM THOMAS MYNES TO JON LILLIENDAHL * * *
The following is a summary of information received from the Oregon Health Authority's Radiation Protection Services via email:
The licensee provided a written report of the event, including the following situation summary. "During post-delivery SPECT/CT acquisition performed at 1015, it was noted that the Y-90 Theraspheres appeared to be in a non-targeted area. The Authorized User (AU) was immediately contacted and came to review the post-delivery images and agreed that the Y-90 Theraspheres were not delivered as a right lobar delivery. After extensive review of SPECT/CT images, it was determined that the delivery was to a metastatic lymph node situated in the liver hilum. Post-delivery measurements confirmed 97.7 percent delivery per vial and 103 percent actual radiation dose to target tissue versus the desired dose. Radiation dose to perfused tissue was 123.6 Gy."
The licensee provided findings and mitigation including planned follow up for the patient with their oncologist.
Notified NMSS Event Notification (email) and NMSS (Allen).
EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT
The following is a summary of information provided by the Oregon Health Authority's Radiation Protection Services (RPS) via phone and email:
On October 13, 2026, RPS was notified by the licensee of activity delivered outside the intended target during a Y-90 microsphere treatment for liver cancer.
The written directive prescribed administration of 5.67 GBq to the right lobe of the liver for a target dose of 120 Gy. The licensee estimated the delivered dose to be approximately 123 Gy.
A post-treatment Bremsstrahlung scan indicated that delivery was segmental to the caudate lobe of the liver and surrounding tissue. Two SPEC-CT scans were performed and revealed delivery near the gallbladder fossa (patient does not have a gallbladder). The authorized user determined that activity was delivered outside the intended area, with some in the liver and some in the tissue or ductal interworking around the liver.
The patient was informed of the findings. A written report, containing all information required under 10 CFR 35.3045(d), will be submitted within 15 days of discovery.
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.
* * * UPDATE ON 10/28/2026 AT 1419 EDT FROM THOMAS MYNES TO JON LILLIENDAHL * * *
The following is a summary of information received from the Oregon Health Authority's Radiation Protection Services via email:
The licensee provided a written report of the event, including the following situation summary. "During post-delivery SPECT/CT acquisition performed at 1015, it was noted that the Y-90 Theraspheres appeared to be in a non-targeted area. The Authorized User (AU) was immediately contacted and came to review the post-delivery images and agreed that the Y-90 Theraspheres were not delivered as a right lobar delivery. After extensive review of SPECT/CT images, it was determined that the delivery was to a metastatic lymph node situated in the liver hilum. Post-delivery measurements confirmed 97.7 percent delivery per vial and 103 percent actual radiation dose to target tissue versus the desired dose. Radiation dose to perfused tissue was 123.6 Gy."
The licensee provided findings and mitigation including planned follow up for the patient with their oncologist.
Notified NMSS Event Notification (email) and NMSS (Allen).
Agreement State
Event Number: 58504
Rep Org: California Dept of Public Health
Licensee: Kaiser Permanente Southern CA
Region: 4
City: Los Angeles State: CA
County:
License #: 0372-19
Agreement: Y
Docket:
NRC Notified By: L. Robert Greger
HQ OPS Officer: Robert A. Thompson
Licensee: Kaiser Permanente Southern CA
Region: 4
City: Los Angeles State: CA
County:
License #: 0372-19
Agreement: Y
Docket:
NRC Notified By: L. Robert Greger
HQ OPS Officer: Robert A. Thompson
Notification Date: 10/22/2026
Notification Time: 20:23 [ET]
Event Date: 10/21/2026
Event Time: 00:00 [PDT]
Last Update Date: 10/22/2026
Notification Time: 20:23 [ET]
Event Date: 10/21/2026
Event Time: 00:00 [PDT]
Last Update Date: 10/22/2026
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
NMSS_EVENTS_NOTIFICATION (EMAIL)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - MEDICAL EVENT
The following information was provided by the Radiologic Health Branch (RHB) of the California Department of Public Health via email:
"A medical event occurred involving an underdose during a Y-90 TheraSphere treatment for a liver lesion. The prescribed activity was 0.65 GBq (17.1 mCi), with a prescribed dose of 680 Gy to the treatment site. Following the procedure, imaging of the patient and the waste container indicated that none of the intended activity had been delivered to the patient. The licensee determined that the entire prescribed activity was retained within the microcatheter tubing, likely due to a kink or obstruction associated with the patient's tortuous vasculature. As a result, the patient did not receive any of the prescribed treatment.
"The licensee will conduct a full investigation of the incident. A written follow up report will be submitted within 15 days in accordance with applicable reporting requirements."
5010 number: 102226
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 Radiologic Health Branch (RHB) of the California Department of Public Health via email:
"A medical event occurred involving an underdose during a Y-90 TheraSphere treatment for a liver lesion. The prescribed activity was 0.65 GBq (17.1 mCi), with a prescribed dose of 680 Gy to the treatment site. Following the procedure, imaging of the patient and the waste container indicated that none of the intended activity had been delivered to the patient. The licensee determined that the entire prescribed activity was retained within the microcatheter tubing, likely due to a kink or obstruction associated with the patient's tortuous vasculature. As a result, the patient did not receive any of the prescribed treatment.
"The licensee will conduct a full investigation of the incident. A written follow up report will be submitted within 15 days in accordance with applicable reporting requirements."
5010 number: 102226
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.