ENS Event | |
|---|---|
07:00 Sep 28, 2018 | |
| Title | Agreement State - Underdosage of Yttrium 90 Theraspheres |
| Event Description | The following was received via email from the State of California:
On 09/28/18, [the Radiation Safety Officer] RSO initially contacted [Radiologic Health Branch] RHB to report a problem related to patient therapy treatment with Yttrium 90 TheraSpheres performed on 09/28/18. The intended activity of the dosage was 11.9 milliCurie, but only approximately 36 percent was delivered to the target tissue based on the measurement of activity remaining in the delivery system after the procedure. The desired dose for the target volume was 135 Gy and the dose delivered was 49 Gy. At the time of the RSO contact, the licensee was uncertain whether the problem was due to patient stasis or an issue with the delivery system (e.g., a kink in the catheter). On 10/02/18, RHB received an email from the RSO stating that the physician (Authorized User) had used a micro catheter on the thinner end and it was very tortuous and made the resistance in the circuit higher than the administration box can tolerate such that the delivery system was not able to work properly in this situation. Licensee stated that the problem was not due to patient stasis. The licensee will submit a written report in accordance with 10 CFR 35.3945(d). California Report No. 5010-092818 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 | |
|---|---|
| Santa Clara Valley Health And Hospital System San Jose, California (NRC Region 4) | |
| License number: | 0741-43 |
| Organization: | California Radiation Control Prgm |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+125.1 h5.213 days <br />0.745 weeks <br />0.171 months <br />) | |
| Opened: | Robert Greger 12:06 Oct 3, 2018 |
| NRC Officer: | Ryan Alexander |
| Last Updated: | Oct 3, 2018 |
| 53639 - NRC Website | |
Santa Clara Valley Health And Hospital System with Agreement State | |
WEEKMONTHYEARENS 536392018-09-28T07:00:00028 September 2018 07:00:00
[Table view]Agreement State Agreement State - Underdosage of Yttrium 90 Theraspheres 2018-09-28T07:00:00 | |