Event Notification Report for September 12, 2022
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
09/11/2022 - 09/12/2022
EVENT NUMBERS
56104
56104
Agreement State
Event Number: 56104
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: Joji Ortego
HQ OPS Officer: Ernest West
Licensee: Cedars Sinai Medical Center
Region: 4
City: Los Angeles State: CA
County:
License #: 0404-19
Agreement: Y
Docket:
NRC Notified By: Joji Ortego
HQ OPS Officer: Ernest West
Notification Date: 09/12/2022
Notification Time: 06:26 [ET]
Event Date: 09/12/2022
Event Time: 00:00 [PDT]
Last Update Date: 09/12/2022
Notification Time: 06:26 [ET]
Event Date: 09/12/2022
Event Time: 00:00 [PDT]
Last Update Date: 09/12/2022
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Drake, James (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Drake, James (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - UNDERDOSE OF Y-90 MICROSPHERES
The following was submitted by the California Department of Public Health by email:
"On Sept. 12, 2022, the RSO of Cedars Sinai Medical Center (CSMC) contacted Los Angeles County Public Health, Radiation Management (LA County) to report a medical event that ocurred at CSMC.
"During administraton of Y-90 Theraspheres to a patient, the Y-90 spheres were stuck in the microcatheter and the Authorized User (AU) was unable to administer the full dosage. The dosage drawn in the syringe was approximately 1.77 GBq (48 mCi) but only 1.05 GBq (28 mCi) was administered, a residual dosage of 40.7 percent [not administered]. Additionally, the prescribed dose to the target organ, liver, was 124 Gy (12,400 rad). The liver received a dose of approximately 71 Gy (7,100 rad), a difference of 5.3 Gy (5,300 rad).
"The RSO has initiated an investigation and the AU will be providing a detailed report."
California Reference Number: 091222
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 was submitted by the California Department of Public Health by email:
"On Sept. 12, 2022, the RSO of Cedars Sinai Medical Center (CSMC) contacted Los Angeles County Public Health, Radiation Management (LA County) to report a medical event that ocurred at CSMC.
"During administraton of Y-90 Theraspheres to a patient, the Y-90 spheres were stuck in the microcatheter and the Authorized User (AU) was unable to administer the full dosage. The dosage drawn in the syringe was approximately 1.77 GBq (48 mCi) but only 1.05 GBq (28 mCi) was administered, a residual dosage of 40.7 percent [not administered]. Additionally, the prescribed dose to the target organ, liver, was 124 Gy (12,400 rad). The liver received a dose of approximately 71 Gy (7,100 rad), a difference of 5.3 Gy (5,300 rad).
"The RSO has initiated an investigation and the AU will be providing a detailed report."
California Reference Number: 091222
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.