ENS 52259

v t e ENS Event
07:00 Sep 22, 2016
Title	Agreement State Report - Patient Underdosage of Yttrium-90
Event Description	The following report was received from the California Department of Public Health via email: On September 23, 2016, the Radiation Safety Officer of the University of California, Los Angeles (UCLA), contacted the Brea office of the Radiologic Health Branch to report a medical event. A patient was treated with Nordion TheraSpheres containing yttrium-90 (Y-90) on September 22, 2016. The prescribed dose was 100 gray (Gy) to the left lobe of the liver. Upon completing the dose assessment after the treatment, it was discovered that only approximately 50 percent of the intended dosage of Y-90 was delivered to the patient (left lobe of the liver). The remainder of the Y-90 dosage appears to have remained in the delivery system, primarily in the system waste container. The licensee performed surveys to confirm that the areas surrounding the delivery system and patient were not contaminated. The patient has been notified, and the licensee is investigating to determine the cause of the event. CA 5010 Number: 092316 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 52259 +/-
Where
Regents Of The University Of California, Los Angeles Los Angeles, California (NRC Region 4)
License number:	1335-19
Organization:	California Radiation Control Prgm
Reporting

Agreement State
Time - Person (Reporting Time:+34.95 h1.456 days <br />0.208 weeks <br />0.0479 months <br />)
Opened:	Andrew Taylor 17:57 Sep 23, 2016
NRC Officer:	Jeff Herrera
Last Updated:	Sep 23, 2016
52259 - NRC Website
v • d • e

v t e Emergency Notification System
Regents Of The University Of California, Los Angeles with Agreement State
WEEKMONTHYEAR2021-01-08T08:00:00 [Table view]
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