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Event Notification Report for October 03, 2024

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
10/02/2024 - 10/03/2024

EVENT NUMBERS
57340 57341
Agreement State
Event Number: 57340
Rep Org: New York State Dept. of Health
Licensee: Mt. Sinai Hospital
Region: 1
City: New York   State: NY
County:
License #: 75-2909-04
Agreement: Y
Docket:
NRC Notified By: Erik Finkelstein
HQ OPS Officer: Ian Howard
Notification Date: 09/26/2024
Notification Time: 11:01 [ET]
Event Date: 09/06/2024
Event Time: 00:00 [EDT]
Last Update Date: 09/26/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Dimitriadis, Anthony (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
AGREEMENT STATE REPORT - MEDICAL UNDERDOSE

The following information was provided by the New York State Department of Health via phone and email:

"Notification was received by email on 9/13/24 from Mt. Sinai Hospital, NYC license number 75-2909-04, of an event that took place on 9/6/24. The event involved treatment of the liver with Y-90 microspheres, and only 40 percent of the intended dose was delivered, which they said was due to stasis. The dose delivered to the left lobe of the liver was 58.8 Gy compared to a prescribed dose of 147 Gy."

NYC Event Number: NYC-24-0913

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: 57341
Rep Org: New York State Dept. of Health
Licensee: Memorial Sloan Kettering Cancer Center
Region: 1
City: New York   State: NY
County:
License #: 75-2968-01
Agreement: Y
Docket:
NRC Notified By: Erik Finkelstein
HQ OPS Officer: Ian Howard
Notification Date: 09/26/2024
Notification Time: 11:01 [ET]
Event Date: 09/24/2024
Event Time: 00:00 [EDT]
Last Update Date: 09/26/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Dimitriadis, Anthony (R1DO)
Fisher, Jennifer (NMSS)
NMSS_Events_Notification, (EMAIL)
Event Text
AGREEMENT STATE REPORT - MEDICAL MISADMINISTRATION

The following information was provided by the New York State Department of Health via phone and email:

"Notification was received by phone call on 9/24/24 and email on 9/26/24, from Memorial Sloan Kettering Cancer Center, NYC license number 75-2968-01, of an event that took place (or was discovered) on 9/24/24. They say the event involved a Y-90 microsphere procedure with a dose to a site other than the treatment site that exceeded 0.5 Sv and was 50 percent or more in excess of the dose expected."

The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:

The unintended dose was to the stomach and duodenum. The estimated excess dose to the affected tissue was 99 Gy. This information is tentative pending further investigation.

NYC Event Number: NYC-24-0924

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.