ENS 52890

v t e ENS Event
07:00 Aug 4, 2017
Title	Agreement State Report - Y-90 Treatment Underdose
Event Description	The following information was provided by the State of California via email: The RSO [Radiation Safety Officer] of Loma Linda Medical Center notified the RHB [Radiologic Health Branch] Brea ICE [Inspection, Compliance and Enforcement] office on August 7, 2017, that a medical event occurred on Friday, August 4, 2017. A patient was admitted to the hospital for treatment of liver carcinoma. The treatment plan involved use of Nordion model TheraSpheres (Y-90 glass microspheres manual brachytherapy) for radio-embolism to the right lobe of the liver. The patient's written directive called for aggregate treatment of 121Gy (5.241 GBq) of Y-90 to the right lobe target area, but only 9.7 Gy (0.420 GBq) was delivered. The overall percent delivery to target tissue was 8.1%. The patient's lung dose from shunting was 1.01 Gy at 4.8% lung shunting factor. The patient and referring physician were informed of the event on 8/4/2017. The medical event is still being investigated, but is thought that a slow injection flowrate may have caused sedimentation of the microspheres in the delivery system. After a few days for decay, a more intensive review of the delivery system will be conducted. CA 5010 Number: 080417 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 52890 +/-
Where
Loma Linda Medical Center San Bernardino, California (NRC Region 4)
License number:	0060-36
Organization:	California Radiation Control Prgm
Reporting

Agreement State
Time - Person (Reporting Time:+106.2 h4.425 days <br />0.632 weeks <br />0.145 months <br />)
Opened:	Kathleen Harkness 17:12 Aug 8, 2017
NRC Officer:	Dong Park
Last Updated:	Aug 8, 2017
52890 - NRC Website
v • d • e

v t e Emergency Notification System
Loma Linda Medical Center with Agreement State
WEEKMONTHYEAR2021-01-25T08:00:00 [Table view]
[ENS list for Loma Linda Medical Center]

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