Event Notification Report for February 11, 2025
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
02/10/2025 - 02/11/2025
EVENT NUMBERS
57546
57546
Agreement State
Event Number: 57546
Rep Org: MA Radiation Control Program
Licensee: Beth Israel Deaconess Medical Center
Region: 1
City: Boston State: MA
County:
License #: 60-0432
Agreement: Y
Docket:
NRC Notified By: Bob Locke
HQ OPS Officer: Ernest West
Licensee: Beth Israel Deaconess Medical Center
Region: 1
City: Boston State: MA
County:
License #: 60-0432
Agreement: Y
Docket:
NRC Notified By: Bob Locke
HQ OPS Officer: Ernest West
Notification Date: 02/14/2025
Notification Time: 11:37 [ET]
Event Date: 02/11/2025
Event Time: 00:00 [EST]
Last Update Date: 02/14/2025
Notification Time: 11:37 [ET]
Event Date: 02/11/2025
Event Time: 00:00 [EST]
Last Update Date: 02/14/2025
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Henrion, Mark (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Henrion, Mark (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - MEDICAL EVENT
The following information was provided by the Massachusetts Radiation Control Program (MRCP) via email:
"On 02/13/25, at 1138 EST, the licensee, Beth Israel Deaconess Medical Center (Massachusetts license number: 60-0432) reported a medical event involving yttrium-90 Theraspheres (Manufacturer: Nordion BWXT ITG Canada, Inc.; Model: TheraSphere Y-90 glass microsphere system; sealed source and device registration number: NR-0220-D-131-S). The total administered activity differed from prescribed treatment activity as documented in the written directive by 20 percent or more.
"The medical event occurred on 2/11/25. The activity delivered was calculated to be 45.5 percent of the prescribed activity (prescribed activity: 4.13 GBq, delivered activity: 1.88 GBq). The event was identified on 2/12/25. The licensee reported that there was no adverse effect on the patient. The authorized user, referring physician, and patient have been notified.
"MRCP will follow up with the licensee's radiation safety officer (RSO) to determine event cause and corrective actions. The device has been taken out of service while the investigation remains open.
"The MRCP considers this event open. The MRCP will follow up with a special inspection of the licensee."
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 information was provided by the Massachusetts Radiation Control Program (MRCP) via email:
"On 02/13/25, at 1138 EST, the licensee, Beth Israel Deaconess Medical Center (Massachusetts license number: 60-0432) reported a medical event involving yttrium-90 Theraspheres (Manufacturer: Nordion BWXT ITG Canada, Inc.; Model: TheraSphere Y-90 glass microsphere system; sealed source and device registration number: NR-0220-D-131-S). The total administered activity differed from prescribed treatment activity as documented in the written directive by 20 percent or more.
"The medical event occurred on 2/11/25. The activity delivered was calculated to be 45.5 percent of the prescribed activity (prescribed activity: 4.13 GBq, delivered activity: 1.88 GBq). The event was identified on 2/12/25. The licensee reported that there was no adverse effect on the patient. The authorized user, referring physician, and patient have been notified.
"MRCP will follow up with the licensee's radiation safety officer (RSO) to determine event cause and corrective actions. The device has been taken out of service while the investigation remains open.
"The MRCP considers this event open. The MRCP will follow up with a special inspection of the licensee."
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.