ENS Event | |
|---|---|
07:00 Aug 4, 2017 | |
| Title | |
| 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. |
| 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 | |
Loma Linda Medical Center with Agreement State | |
WEEKMONTHYEARENS 550842021-01-25T08:00:00025 January 2021 08:00:00
[Table view]Agreement State Incorrect Dose Delivered to Patient ENS 528902017-08-04T07:00:0004 August 2017 07:00:00 Agreement State Agreement State Report - Y-90 Treatment Underdose ENS 519732016-05-27T07:00:00027 May 2016 07:00:00 Agreement State Agreement State Report - Brachytherapy Underdose ENS 483892012-05-23T07:00:00023 May 2012 07:00:00 Agreement State Agreement State Report - Potential Medical Event ENS 405942004-03-16T08:00:00016 March 2004 08:00:00 Agreement State Agreement State Report - Missing Sr-90 Eye Applicator Source 2021-01-25T08:00:00 | |