Event Notification Report for February 25, 2025
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
02/24/2025 - 02/25/2025
Agreement State
Event Number: 57571
Rep Org: California Radiation Control Prgm
Licensee: Hoag Hospital Irvine
Region: 4
City: Irvine State: CA
County:
License #: 8034-30
Agreement: Y
Docket:
NRC Notified By: Robert Greger
HQ OPS Officer: Kerby Scales
Licensee: Hoag Hospital Irvine
Region: 4
City: Irvine State: CA
County:
License #: 8034-30
Agreement: Y
Docket:
NRC Notified By: Robert Greger
HQ OPS Officer: Kerby Scales
Notification Date: 02/25/2025
Notification Time: 19:22 [ET]
Event Date: 02/25/2025
Event Time: 00:00 [PST]
Last Update Date: 02/25/2025
Notification Time: 19:22 [ET]
Event Date: 02/25/2025
Event Time: 00:00 [PST]
Last Update Date: 02/25/2025
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Roldan-Otero, Lizette (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Roldan-Otero, Lizette (R4DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - MEDICAL EVENT
The following information was received from the California Department of Health (CDPH) via email:
"The radiation safety officer for Hoag Hospital in Irvine called the California Office of Emergency Services to report a potential medical event that occurred during a research treatment that involved a targeted alpha radionuclide therapy. The authorized user prescribed 289 microcuries of Ac-225 in the form of FPI-2265 also known as [225Ac] PMSA imaging therapy; however, the Biodex pump used to administer the dose leaked, and only approximately 80 microcuries were administered.
"The treatment was for metastatic castrate resistant prostate cancer primarily located in bone marrow. CDPH will conduct an investigation of the circumstances of the medical event."
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 received from the California Department of Health (CDPH) via email:
"The radiation safety officer for Hoag Hospital in Irvine called the California Office of Emergency Services to report a potential medical event that occurred during a research treatment that involved a targeted alpha radionuclide therapy. The authorized user prescribed 289 microcuries of Ac-225 in the form of FPI-2265 also known as [225Ac] PMSA imaging therapy; however, the Biodex pump used to administer the dose leaked, and only approximately 80 microcuries were administered.
"The treatment was for metastatic castrate resistant prostate cancer primarily located in bone marrow. CDPH will conduct an investigation of the circumstances of the medical event."
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: 57580
Rep Org: Florida Bureau of Radiation Control
Licensee: Comprehensive Hematology Oncology
Region: 1
City: Trinity State: FL
County:
License #: 4657-3
Agreement: Y
Docket:
NRC Notified By: Monroe A. Cooper
HQ OPS Officer: Ernest West
Licensee: Comprehensive Hematology Oncology
Region: 1
City: Trinity State: FL
County:
License #: 4657-3
Agreement: Y
Docket:
NRC Notified By: Monroe A. Cooper
HQ OPS Officer: Ernest West
Notification Date: 03/03/2025
Notification Time: 12:37 [ET]
Event Date: 02/25/2025
Event Time: 00:00 [EST]
Last Update Date: 03/04/2025
Notification Time: 12:37 [ET]
Event Date: 02/25/2025
Event Time: 00:00 [EST]
Last Update Date: 03/04/2025
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Ford, Monica (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Miller, Andy (NMSS)
Ford, Monica (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Miller, Andy (NMSS)
EN Revision Imported Date: 3/11/2025
EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT
The following is a summary of information provided by the State of Florida, Bureau of Radiation Control (the BRC) via email:
"[BRC was notified of a medical event involving a high dose rate (HDR) prostate treatment that] occurred on 2/25/25, was identified during the weekend of 3/1/25 to 3/2/25, and was determined to have been a medical event by the facility on 3/3/25. During [delivery of] the second fraction of two fractions, Comprehensive Hematology Oncology incorrectly typed the catheter length into the procedure's software. This resulted in the dose being received 5 cm short of the intended location. The prostate received no dose during this fraction, and the rectum received an estimated 60 percent of its expected dose. The patient and primary physician have been notified. The second fraction has been rescheduled."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
The prescribed dose for the second fraction of the HDR prostate treatment was unknown at the time of the notification. This event is similar but involved a different patient than EN 57581 (FL25-019).
Florida Incident Number: FL25-018
* * * UPDATE ON 03/04/2025 AT 0847 EST FROM MONROE COOPER TO ROBERT THOMPSON * * *
Current information, retrieved by BRC, states that the intended total dose was 2700 cGy delivered over two fractions.
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.
EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT
The following is a summary of information provided by the State of Florida, Bureau of Radiation Control (the BRC) via email:
"[BRC was notified of a medical event involving a high dose rate (HDR) prostate treatment that] occurred on 2/25/25, was identified during the weekend of 3/1/25 to 3/2/25, and was determined to have been a medical event by the facility on 3/3/25. During [delivery of] the second fraction of two fractions, Comprehensive Hematology Oncology incorrectly typed the catheter length into the procedure's software. This resulted in the dose being received 5 cm short of the intended location. The prostate received no dose during this fraction, and the rectum received an estimated 60 percent of its expected dose. The patient and primary physician have been notified. The second fraction has been rescheduled."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
The prescribed dose for the second fraction of the HDR prostate treatment was unknown at the time of the notification. This event is similar but involved a different patient than EN 57581 (FL25-019).
Florida Incident Number: FL25-018
* * * UPDATE ON 03/04/2025 AT 0847 EST FROM MONROE COOPER TO ROBERT THOMPSON * * *
Current information, retrieved by BRC, states that the intended total dose was 2700 cGy delivered over two fractions.
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: 57581
Rep Org: Florida Bureau of Radiation Control
Licensee: Comprehensive Hematology Oncology
Region: 1
City: Trinity State: FL
County:
License #: 4657-3
Agreement: Y
Docket:
NRC Notified By: Monroe A. Cooper
HQ OPS Officer: Josue Ramirez
Licensee: Comprehensive Hematology Oncology
Region: 1
City: Trinity State: FL
County:
License #: 4657-3
Agreement: Y
Docket:
NRC Notified By: Monroe A. Cooper
HQ OPS Officer: Josue Ramirez
Notification Date: 03/03/2025
Notification Time: 12:39 [ET]
Event Date: 02/25/2025
Event Time: 00:00 [EST]
Last Update Date: 03/04/2025
Notification Time: 12:39 [ET]
Event Date: 02/25/2025
Event Time: 00:00 [EST]
Last Update Date: 03/04/2025
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Ford, Monica (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Miller, Andy (NMSS)
Ford, Monica (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Miller, Andy (NMSS)
EN Revision Imported Date: 3/11/2025
EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT
The following is a summary of information provided by the State of Florida, Bureau of Radiation Control (the BRC) via email:
"[BRC was notified of a medical event involving a high dose rate (HDR) prostate treatment that] occurred on 2/25/25, was identified during the weekend of 3/1/25 to 3/2/25, and was determined to have been a medical event by the facility on 3/3/25. During [delivery of] the second fraction of two fractions, Comprehensive Hematology Oncology incorrectly typed the catheter length into the procedure's software. This resulted in the dose being received 5 cm short of the intended location. The prostate received no dose during this fraction, and the rectum received an estimated 60 percent of its expected dose. The patient and primary physician have been notified. The second fraction has been rescheduled."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
The prescribed dose for the second fraction of the HDR prostate treatment was unknown at the time of the notification. This event is similar but involved a different patient than EN 57580 (FL25-018).
Florida Incident Number: FL25-019
* * * UPDATE ON 03/04/2025 AT 0847 EST FROM MONROE COOPER TO ROBERT THOMPSON * * *
Current information, retrieved by BRC, states that the intended total dose was 2700 cGy delivered over two fractions.
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.
EN Revision Text: AGREEMENT STATE REPORT - MEDICAL EVENT
The following is a summary of information provided by the State of Florida, Bureau of Radiation Control (the BRC) via email:
"[BRC was notified of a medical event involving a high dose rate (HDR) prostate treatment that] occurred on 2/25/25, was identified during the weekend of 3/1/25 to 3/2/25, and was determined to have been a medical event by the facility on 3/3/25. During [delivery of] the second fraction of two fractions, Comprehensive Hematology Oncology incorrectly typed the catheter length into the procedure's software. This resulted in the dose being received 5 cm short of the intended location. The prostate received no dose during this fraction, and the rectum received an estimated 60 percent of its expected dose. The patient and primary physician have been notified. The second fraction has been rescheduled."
The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance:
The prescribed dose for the second fraction of the HDR prostate treatment was unknown at the time of the notification. This event is similar but involved a different patient than EN 57580 (FL25-018).
Florida Incident Number: FL25-019
* * * UPDATE ON 03/04/2025 AT 0847 EST FROM MONROE COOPER TO ROBERT THOMPSON * * *
Current information, retrieved by BRC, states that the intended total dose was 2700 cGy delivered over two fractions.
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.