Event Notification Report for February 03, 2021

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
02/02/2021 - 02/03/2021

EVENT NUMBERS
55084
Agreement State
Event Number: 55084
Rep Org: CALIFORNIA RADIATION CONTROL PRGM
Licensee: Loma Linda Medical Center
Region: 4
City: Loma Linda   State: CA
County:
License #: 0060-36
Agreement: Y
Docket:
NRC Notified By: Robert Greger
HQ OPS Officer: Brian Lin
Notification Date: 01/26/2021
Notification Time: 17:04 [ET]
Event Date: 01/25/2021
Event Time: 00:00 [PST]
Last Update Date: 01/26/2021
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
JAMES DRAKE (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - INCORRECT DOSE DELIVERED TO PATIENT

The following information was received from the state of California via email:

"On January 25, 2021, the Radiation Safety Officers [RSO] discovered and reported to CDPH [California Department of Public Health] that a medical event had occurred on December 28, 2020. The RSO stated that during a routine review of the past month's radiation therapies, they discovered that a Y-90 Nordion TheraSphere treatment performed on 12/28/2020 resulted in a delivered dose that was approximately 33 percent greater than the physician's written directive (550 Gy) signed on 12/15/2020. This higher patient dose was the result of administering the dose on Monday (12/28/2020) that was calibrated for administration on Tuesday (12/29/2020). The licensee will be submitting their 15 day report per 10 CFR 35.3045."

California report no.: 012521

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.

Page Last Reviewed/Updated Wednesday, February 03, 2021