Event Notification Report for August 13, 2024
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
08/12/2024 - 08/13/2024
Agreement State
Event Number: 57263
Rep Org: California Radiation Control Prgm
Licensee: Regents of the UCLA
Region: 4
City: Los Angeles State: CA
County:
License #: 1335-19
Agreement: Y
Docket:
NRC Notified By: Donald Oesterle
HQ OPS Officer: Ian Howard
Notification Date: 08/06/2024
Notification Time: 21:30 [ET]
Event Date: 08/05/2024
Event Time: 15:15 [PDT]
Last Update Date: 08/06/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Vossmar, Patricia (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - MEDICAL UNDERDOSE
The following report was received by the California Department of Public Health, Radiation Health Branch (RHB) via email:
"The University of California, Los Angeles (UCLA) reported a medical event that had occurred on Monday, August 5, 2024, during a Y-90 Sirtex SIR-Sphere liver cancer treatment.
"The target organ was the patient's left liver lobe. The authorized user prescribed an activity of 0.71 GBq (19.14 mCi).
"Unfortunately, the target organ only received 7.72 mCi or 40.33 percent of the prescribed dose.
"The interventional radiologist reported that the cause of the under-delivery was a leak in the SIR-Sphere tubing system (delivery box and covered table). All contaminated equipment is being held for decay by UCLA.
"UCLA will submit a 15-day written report to the RHB."
California Event Number: 080524
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.