Event Notification Report for January 30, 2024
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
01/29/2024 - 01/30/2024
Agreement State
Event Number: 56940
Rep Org: California Radiation Control Prgm
Licensee: Cedars Sinai Medical Center
Region: 4
City: Los Angeles State: CA
County:
License #: 0404-19
Agreement: Y
Docket:
NRC Notified By: L. Robert Greger
HQ OPS Officer: Natalie Starfish
Licensee: Cedars Sinai Medical Center
Region: 4
City: Los Angeles State: CA
County:
License #: 0404-19
Agreement: Y
Docket:
NRC Notified By: L. Robert Greger
HQ OPS Officer: Natalie Starfish
Notification Date: 01/30/2024
Notification Time: 19:48 [ET]
Event Date: 01/30/2024
Event Time: 14:50 [PST]
Last Update Date: 01/30/2024
Notification Time: 19:48 [ET]
Event Date: 01/30/2024
Event Time: 14:50 [PST]
Last Update Date: 01/30/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Agrawal, Ami (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Agrawal, Ami (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE - Y-90 UNDERDOSE
The following is a summary of information that was provided by the California Department of Public Health, Radiological Health Branch via email:
On January 30, 2024, at 1450 PST, the radiation safety officer of Cedars Sinai Medical Center contacted the Los Angeles County Radiation Management office to report a medical underdose event. The underdose occurred during a treatment of Y-90 (yttrium-90) TheraSpheres microspheres for a radioembolization treatment for liver cancer. The prescribed activity was 480 Gy and the administered activity was 227.6 Gy (about 47 percent of the prescription). The underdose was due to an obstruction of the microcatheter used to deliver the Y-90. The patient has been notified.
Cedars Sinai Medical Center will conduct an investigation to gain a better understanding of the details of the event.
CA event ID number: 013024
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 is a summary of information that was provided by the California Department of Public Health, Radiological Health Branch via email:
On January 30, 2024, at 1450 PST, the radiation safety officer of Cedars Sinai Medical Center contacted the Los Angeles County Radiation Management office to report a medical underdose event. The underdose occurred during a treatment of Y-90 (yttrium-90) TheraSpheres microspheres for a radioembolization treatment for liver cancer. The prescribed activity was 480 Gy and the administered activity was 227.6 Gy (about 47 percent of the prescription). The underdose was due to an obstruction of the microcatheter used to deliver the Y-90. The patient has been notified.
Cedars Sinai Medical Center will conduct an investigation to gain a better understanding of the details of the event.
CA event ID number: 013024
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.
Power Reactor
Event Number: 56939
Facility: Limerick
Region: 1 State: PA
Unit: [1] [2] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: Bill Bulafka
HQ OPS Officer: Karen Cotton-Gross
Region: 1 State: PA
Unit: [1] [2] []
RX Type: [1] GE-4,[2] GE-4
NRC Notified By: Bill Bulafka
HQ OPS Officer: Karen Cotton-Gross
Notification Date: 01/30/2024
Notification Time: 18:56 [ET]
Event Date: 01/30/2024
Event Time: 09:37 [EST]
Last Update Date: 01/30/2024
Notification Time: 18:56 [ET]
Event Date: 01/30/2024
Event Time: 09:37 [EST]
Last Update Date: 01/30/2024
Emergency Class: Non Emergency
10 CFR Section:
26.719 - Fitness For Duty
10 CFR Section:
26.719 - Fitness For Duty
Person (Organization):
Dentel, Glenn (R1DO)
FFD Group, (EMAIL)
Dentel, Glenn (R1DO)
FFD Group, (EMAIL)
| Unit | SCRAM Code | RX Crit | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode |
|---|---|---|---|---|---|---|
| 1 | N | Y | 100 | Power Operation | 100 | Power Operation |
| 2 | N | Y | 100 | Power Operation | 100 | Power Operation |
FITNESS FOR DUTY
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
On January 30, 2024, a non-licensed employee supervisor, after investigation, was determined to be in involved with a controlled substance. The employee's access to the site has been placed on administrative hold, pending further investigation.
The NRC Resident Inspector has been notified.
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
On January 30, 2024, a non-licensed employee supervisor, after investigation, was determined to be in involved with a controlled substance. The employee's access to the site has been placed on administrative hold, pending further investigation.
The NRC Resident Inspector has been notified.