Event Notification Report for April 14, 2025
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
04/13/2025 - 04/14/2025
EVENT NUMBERS
57668
57668
Agreement State
Event Number: 57668
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: Thomas Miko
HQ OPS Officer: Brian P. Smith
Licensee: Cedars Sinai Medical Center
Region: 4
City: Los Angeles State: CA
County:
License #: 0404-19
Agreement: Y
Docket:
NRC Notified By: Thomas Miko
HQ OPS Officer: Brian P. Smith
Notification Date: 04/16/2025
Notification Time: 13:57 [ET]
Event Date: 04/14/2025
Event Time: 00:00 [PDT]
Last Update Date: 04/16/2025
Notification Time: 13:57 [ET]
Event Date: 04/14/2025
Event Time: 00:00 [PDT]
Last Update Date: 04/16/2025
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 - 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
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