ENS 50647

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v t e ENS Event
08:00 Nov 7, 2014
Title	Agreement State - Medical Event Involving Underdosage to Patient of Y-90 Sir-Spheres
Event Description	The following is a synopsis of information received via E-mail: The Cedars Sinai Medical Center (CSMC) Radiation Physics Manager (RPM) contacted Los Angeles County Radiation Management (LA County) via telephone to report a potential medical event that had occurred at CSMC. The RPM stated that the event resulted from a dosage administration to the patient of yttrium-90 SIR-Spheres less than that prescribed. LA County requested that a written report be submitted. Per the written report, the treatment plan required administration of 31 milliCuries (mCi) of Y-90 through a catheter via the hepatic artery. During setup, the interventional radiologist (IR) noted a potential air bubble in one of the lines connected to the catheter. The IR disconnected the line and flushed it with solution to clear the air bubble. The IR then activated the SIR-Sphere device without realizing that the line was still disconnected from the catheter. The radioactive material spilled into the sterile 4 inch by 4 inch gauze and drapes on the sterile field. The patient received 13 mCi, which was 42 percent of the prescribed dosage of 31 mCi. The RPM stated that the referring physician and patient were notified and that the patient did not report any side effects as a result of the incorrect dosage administration. Based on CSMC's written report, it was determined that this event required 24-hr notification to the NRC Operations Center. 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 50647 +/-
Where
Cedars Sinai Medical Center Los Angeles, California (NRC Region 4)
License number:	0404-19
Organization:	California Radiation Control Prgm
Reporting

Agreement State
Time - Person (Reporting Time:+609.25 h25.385 days <br />3.626 weeks <br />0.835 months <br />)
Opened:	Josephine Ortego 17:15 Dec 2, 2014
NRC Officer:	Donald Norwood
Last Updated:	Dec 2, 2014
50647 - NRC Website
v • d • e

v t e Emergency Notification System
Cedars Sinai Medical Center with Agreement State
WEEKMONTHYEAR2025-04-14T07:00:00 [Table view]
[ENS list for Cedars Sinai Medical Center]

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