Event Notification Report for September 18, 2025
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
09/17/2025 - 09/18/2025
EVENT NUMBERS
57938
57938
Agreement State
Event Number: 57938
Rep Org: Kentucky Dept of Radiation Control
Licensee: University of Louisville
Region: 1
City: Louisville State: KY
County:
License #: 202-029-22
Agreement: Y
Docket:
NRC Notified By: Russell Hestand
HQ OPS Officer: Adam Koziol
Licensee: University of Louisville
Region: 1
City: Louisville State: KY
County:
License #: 202-029-22
Agreement: Y
Docket:
NRC Notified By: Russell Hestand
HQ OPS Officer: Adam Koziol
Notification Date: 09/18/2025
Notification Time: 10:56 [ET]
Event Date: 09/18/2025
Event Time: 00:00 [CDT]
Last Update Date: 09/18/2025
Notification Time: 10:56 [ET]
Event Date: 09/18/2025
Event Time: 00:00 [CDT]
Last Update Date: 09/18/2025
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Schussler, Jason (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Schussler, Jason (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - MEDICAL EVENT
The following information was provided by the Radiation Health Branch of the Kentucky Department for Public Health and Safety (KY RHB) via email:
"KY RHB was notified on 9/18/2025 by the radiation safety officer (RSO) from the University of Louisville Hospital of an issue with five Sir-Sphere Y-90 doses.
"Due to a software issue that had a calculation error converting GBq to mCi, 5 patients were underdosed to a point that their dose was more than 20 percent outside of the prescribed dose, and the dose to the organ (liver) was more than 50 mSv from the prescribed dose.
"The RSO is meeting with the physician today to discuss the issues. The issue with the software has been fixed."
KY Event Number: TBD
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 Radiation Health Branch of the Kentucky Department for Public Health and Safety (KY RHB) via email:
"KY RHB was notified on 9/18/2025 by the radiation safety officer (RSO) from the University of Louisville Hospital of an issue with five Sir-Sphere Y-90 doses.
"Due to a software issue that had a calculation error converting GBq to mCi, 5 patients were underdosed to a point that their dose was more than 20 percent outside of the prescribed dose, and the dose to the organ (liver) was more than 50 mSv from the prescribed dose.
"The RSO is meeting with the physician today to discuss the issues. The issue with the software has been fixed."
KY Event Number: TBD
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.