ENS 50091

v t e ENS Event
07:00 Apr 30, 2014
Title	Agreement State Report - Incorrect Dosage Administered to Patient
Event Description	I am reporting a Medical Event and Abnormal Occurrence. The event resulted from incorrect dosage administered to the patient for the second phase of the yttrium-90 SirSperes for treatment of the liver. The patient was administered 43 millicuries of Y-90 for the second phase instead of 12 to 12.5 mCi as intended. The event occurred at Cedars Sinai Medical Center (California Radioactive Materials License number 0404-19) in Los Angeles, CA, on April 30, 2014. Los Angeles County Public Health, Radiation Management was notified on May 1, 2014. During the original report date, the licensee did not have any information regarding the radiation dose to the patient and was working with their Medical Physicists. On May 6, 2014, Cedars Sinai Medical Center reported that the patient received 363 Gray instead of the intended dose within the range of 53-102 Gray. Per the licensee, both the patient and referring physicians have been notified. The patient has not reported any side effects that were unanticipated and the patient will continue to be medically monitored. 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.

ENS 50091 +/-
Where
Cedars Sinai Medical Center Los Angeles, California (NRC Region 4)
License number:	CA 0404
Organization:	California Radiation Control Prgm
Reporting

Agreement State
Time - Person (Reporting Time:+152.25 h6.344 days <br />0.906 weeks <br />0.209 months <br />)
Opened:	Josephine Ortego 15:15 May 6, 2014
NRC Officer:	Donald Norwood
Last Updated:	May 6, 2014
50091 - NRC Website
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v t e Emergency Notification System
Cedars Sinai Medical Center with Agreement State
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