Event Notification Report for February 07, 2024
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
02/06/2024 - 02/07/2024
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.
Agreement State
Event Number: 56942
Rep Org: Illinois Emergency Mgmt. Agency
Licensee: Rush University Medical Center
Region: 3
City: Chicago State: IL
County:
License #: IL-01766-01
Agreement: Y
Docket:
NRC Notified By: Whitney Cox
HQ OPS Officer: Natalie Starfish
Licensee: Rush University Medical Center
Region: 3
City: Chicago State: IL
County:
License #: IL-01766-01
Agreement: Y
Docket:
NRC Notified By: Whitney Cox
HQ OPS Officer: Natalie Starfish
Notification Date: 02/01/2024
Notification Time: 15:35 [ET]
Event Date: 01/31/2024
Event Time: 00:00 [CST]
Last Update Date: 02/01/2024
Notification Time: 15:35 [ET]
Event Date: 01/31/2024
Event Time: 00:00 [CST]
Last Update Date: 02/01/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Stoedter, Karla (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Stoedter, Karla (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - MEDICAL UNDERDOSE
The following is a summary of information received by email from the Illinois Office of Nuclear Safety:
On January 31, 2024, a medical administration of Y-90 microspheres at Rush University Medical Center failed to deliver the intended dose. A patient had been prescribed 34.99 mCi (500 Gy) of yttrium-90 (Y-90) Theraspheres intended for a liver treatment. The post-administration survey indicated a delivered dose of only 23.05 mCi (330 Gy), which was a 34 percent underdose. The patient and physician were notified the day of the treatment. There was no adverse impact on the patient and the patient will not need to be retreated. The administering physician reported significant resistance in the initial and subsequent flushes.
IL NMED Item Number: IL240003
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 received by email from the Illinois Office of Nuclear Safety:
On January 31, 2024, a medical administration of Y-90 microspheres at Rush University Medical Center failed to deliver the intended dose. A patient had been prescribed 34.99 mCi (500 Gy) of yttrium-90 (Y-90) Theraspheres intended for a liver treatment. The post-administration survey indicated a delivered dose of only 23.05 mCi (330 Gy), which was a 34 percent underdose. The patient and physician were notified the day of the treatment. There was no adverse impact on the patient and the patient will not need to be retreated. The administering physician reported significant resistance in the initial and subsequent flushes.
IL NMED Item Number: IL240003
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.
Agreement State
Event Number: 56943
Rep Org: Colorado Dept of Health
Licensee: Kumar and Associates Inc
Region: 4
City: Denver State: CO
County:
License #: CO 778-01
Agreement: Y
Docket:
NRC Notified By: Derek Bailey
HQ OPS Officer: Adam Koziol
Licensee: Kumar and Associates Inc
Region: 4
City: Denver State: CO
County:
License #: CO 778-01
Agreement: Y
Docket:
NRC Notified By: Derek Bailey
HQ OPS Officer: Adam Koziol
Notification Date: 02/01/2024
Notification Time: 15:33 [ET]
Event Date: 02/01/2024
Event Time: 10:30 [MST]
Last Update Date: 02/01/2024
Notification Time: 15:33 [ET]
Event Date: 02/01/2024
Event Time: 10:30 [MST]
Last Update Date: 02/01/2024
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 REPORT - POTENTIALLY DAMAGED GAUGE
The following information was provided by the Colorado Department of Public Health and Environment (the Division) via email:
"On Thursday February 1, 2024, at approximately 1030 MST, the Division was notified of a vehicle collision that resulted in the damage of a portable nuclear gauge (Nuclear Gauge - Troxler 3430 SN: 28355).
"The initial report indicated the Type A package containing the nuclear gauge was thrown from the vehicle and both the package and the gauge sustained damage.
"Colorado State Patrol responded to the scene and determined the nuclear gauge was intact, and it was turned over to the licensee.
"The Department confirmed with the licensee the gauge was able to be secured with the source in the shielded position and the shielding for the sources is not compromised. A leak test is being expedited at this time."
Colorado Event Number: CO 240001
The following information was provided by the Colorado Department of Public Health and Environment (the Division) via email:
"On Thursday February 1, 2024, at approximately 1030 MST, the Division was notified of a vehicle collision that resulted in the damage of a portable nuclear gauge (Nuclear Gauge - Troxler 3430 SN: 28355).
"The initial report indicated the Type A package containing the nuclear gauge was thrown from the vehicle and both the package and the gauge sustained damage.
"Colorado State Patrol responded to the scene and determined the nuclear gauge was intact, and it was turned over to the licensee.
"The Department confirmed with the licensee the gauge was able to be secured with the source in the shielded position and the shielding for the sources is not compromised. A leak test is being expedited at this time."
Colorado Event Number: CO 240001