Event Notification Report for April 13, 2025

AGREEMENT STATE REPORT - MEDICAL EVENT

The following report was received by the California Radiation Control Program via email:

"On April 15, 2025, the radiation safety officer at Cedars Sinai Medical Center contacted Los Angeles County Public Health Radiation Management (part of the California Radiation Control Program), first by telephone at 0955 PDT and then by email at 1055 PDT, to report a medical event that occurred at Cedars Sinai Medical Center. During the administration of Y-90 TheraSpheres to a patient, the Y-90 TheraSpheres became obstructed within the intravenous tubing such that the authorized user was unable to administer the full dosage. The activity in the syringe was approximately 35 mCi, but only 12.14 mCi was delivered to the target organ. This was 35 percent of the prescribed activity. Additionally, the prescribed dose to the liver (the target organ) was 78.8 gray [7,880 rads]. The liver received a dose of 27.6 gray [2,760 rads], a difference of 51.2 gray [5,120 rads].

"A site visit by the principal radiation protection specialist, Los Angeles County Public Health Radiation Management is scheduled for April 17, 2025."

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.

California 5010 Number: 041525

MEDICAL TRANSPORT WITH CONTAMINATION

The following information was provided by the licensee via phone and email:

"At approximately 0215 EDT, on April 13, 2025, a uranium recovery and recycle services (URRS) operator was performing a pressure check of a dissolver system filter housing following change out of the filter cartridges. Uranyl nitrate solution discharged from the housing lid/housing body interface onto the operator's coveralls in the upper left arm area. In accordance with the operating procedure, the operator was wearing a full-face shield, safety glasses, chemical gloves, and a chemical apron that covers the torso area. The chemical apron does not cover the arm area.

"The operator reported the exposure to a URRS chief operator and the skin area on the upper left arm was rinsed for approximately fifteen minutes. The incident commander, a medical first responder from the Columbia Fuel Fabrication Facility (CFFF) emergency brigade and a health physics (HP) technician were contacted to respond to the URRS area. After decontamination efforts on the affected area of the arm, HP direct [on contact] survey results were 500 disintegrations per minute (dpm) per 100 cm squared of alpha [radiation] for the left bicep area.

"The filter housing lid was secured properly and passed the pressure check required by the operating procedure. This event did not impact safety equipment. A causal analysis and corrective actions will be documented in the Corrective Action Program (CAP).

"All smear survey results of the exposed skin area were below clean area limits (less than 200 dpm per 100 cm squared). As a precaution to ensure comprehensive evaluation and treatment for uranyl nitrate/nitric acid exposure to the skin, the operator was transported by ambulance to an offsite medical facility. The affected portion of the employee's arm was bandaged and wrapped in gauze and tape, and the employee was accompanied by a CFFF HP technician for evaluation. Contamination surveys were performed for the ambulance and the gurney used to transport the employee, and all results were below clean area limits, indicating no spread of contamination during care for the employee. All potentially contaminated materials associated with the transport were collected and returned to the CFFF for disposal. The employee was provided with an over-the-counter topical ointment and released from the offsite medical facility at 0735 on April 13, 2025.

"The CFFF is a licensed Part 70 facility subject to 10 CFR 70 Subpart H, and the event did not challenge the performance requirements of 10 CFR 70.61 as analyzed in the Integrated Safety Analysis."