ENS Event | |
|---|---|
23:00 Apr 2, 2018 | |
| Title | Agreement State Report - Received Dose Less than Prescribed Dose |
| Event Description | The following was received via email from the state of California:
A medical event per 10 CFR 35.3045 was determined to have occurred on April 2, 2018 during a University of California San Diego (UCSD) Y-90 liver therapy procedure. The total delivered dosage was greater than 20 percent less than the prescribed dosage. The authorized user prescribed MDS Nordion Theraspheres Y-90 activity of 22.7 mCi to be delivered to the left lobe of the patient's liver. During the medical procedure, blockage occurred in the delivery apparatus, and the authorized user was unable to complete the administration of the Y-90 Therasphere dosage. Post-procedural dosage vial chamber measurements were performed that indicated only 32.5 percent (7.4 mCi) of the prescribed Y-90 dosage was delivered. An MDS Nordion representative was observing the procedure. The UCSD campus Radiation Safety office was notified that the administration resulted in a medical event and the California Radiation Health Branch was notified. The patient and their referring physician were notified on April 2, 2018. The patient will be scheduled for another Therasphere administration in the near future to complete the treatment plan. California 5010 Number: 040218 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 | |
|---|---|
| University Of California San Diego La Jolla, California (NRC Region 4) | |
| License number: | 1339-37 |
| Organization: | California Radiation Control Prgm |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+39.33 h1.639 days <br />0.234 weeks <br />0.0539 months <br />) | |
| Opened: | Robert Greger 14:20 Apr 4, 2018 |
| NRC Officer: | Andrew Waugh |
| Last Updated: | Apr 4, 2018 |
| 53314 - NRC Website | |
University Of California San Diego with Agreement State | |
WEEKMONTHYEARENS 533142018-04-02T23:00:0002 April 2018 23:00:00
[Table view]Agreement State Agreement State Report - Received Dose Less than Prescribed Dose 2018-04-02T23:00:00 | |