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Home NRC Library Document Collections Events, Reports Associated with Event Notification Reports 2022

Event Notification Report for May 19, 2022

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
05/18/2022 - 05/19/2022

EVENT NUMBERS
55892
Agreement State
Event Number: 55892
Rep Org: California Radiation Control Prgm
Licensee: City of Hope
Region: 4
City: Duarte   State: CA
County:
License #: 0307-19
Agreement: Y
Docket:
NRC Notified By: Robert Greger
HQ OPS Officer: Donald Norwood
Notification Date: 05/10/2022
Notification Time: 23:57 [ET]
Event Date: 05/10/2022
Event Time: 00:00 [PDT]
Last Update Date: 05/11/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
NMSS_EVENTS_NOTIFICATION (EMAIL)
Gaddy, Vincent (R4DO)
Event Text
AGREEMENT STATE REPORT - UNDERDOSE MEDICAL EVENT

The following information was received via e-mail:

"The City of Hope Radiation Safety Officer contacted LA County Radiation Management (LA County) on May 10, 2022 to report a Medical Event that occurred on the same day at City of Hope in Duarte, CA. The patient was underdosed during a Selective Internal Radiation Therapy (SIRT) treatment for liver cancer that involved the administration of SIR-Spheres yttrium-90 (Y-90) resin microspheres. The prescribed dose to the patient was 10 mCi, but the dose delivered to the patient was only 6.42 mCi due to a leakage caused by a loose tubing connection.

"City of Hope will conduct an investigation to gain a better understanding of the details of the event."

California 5010 Number: 051022

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.