ENS Event | |
|---|---|
08:00 Jan 8, 2021 | |
| Title | Underdose to Patient Undergoing Radiation Treatment |
| Event Description | The following information was received from the Radiologic Health Branch, California Department of Public Health via email:
On Friday, January 8, 2021, the University of California Los Angeles (UCLA) notified the Radiologic Health Branch that a potential medical event involving Y-90 had occurred that day. A liver cancer patient was administered four vials of Y-90 BTG Nordion Inc. TheraSpheres to the patient's liver segments 4, 5, 6 and 7. Segment 4 was prescribed 120 Gy ( 0.86 GBq) and the delivered dose was 110.6 Gy (92.17%). Segment 5 was prescribed 120 Gy (0.86 GBq) and the delivered dose was 113.4 Gy (94.5%). Segment 6 was prescribed 120 Gy (0.86 GBq) and the delivered dose was 111.7 Gy (93.08%). Segment 7 was prescribed 120 Gy (0.86 GBq) and the delivered dose was 50.2 Gy (41.83%), which is less than 20 % of the prescribed amount. Overall, the average of the four administrations to the patient's liver was 80.4%. On January 10, 2021, the Radiologic Health Branch, sent an email to UCLA's Radiation Safety Officer requesting that UCLA's Environmental Health and Safety medical team perform an investigation to try to determine the root cause of the delivery failure for segment 7. They were asked to interview the authorized user and all other personnel attending the procedure and also to provide copies of the authorized user's written directives. The patient was notified of the under-dosage and potential continuation of their cancer treatment. 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 | |
|---|---|
| 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:+78.25 h3.26 days <br />0.466 weeks <br />0.107 months <br />) | |
| Opened: | Kathleen Harkness 14:15 Jan 11, 2021 |
| NRC Officer: | Lloyd Desotell |
| Last Updated: | Jan 11, 2021 |
| 55060 - NRC Website | |
Regents Of The University Of California, Los Angeles with Agreement State | |
WEEKMONTHYEARENS 550602021-01-08T08:00:0008 January 2021 08:00:00
[Table view]Agreement State Underdose to Patient Undergoing Radiation Treatment ENS 539402019-03-14T07:00:00014 March 2019 07:00:00 Agreement State Agreement State - Under-Dosage to Patient ENS 524602016-12-22T08:00:00022 December 2016 08:00:00 Agreement State Agreement State Report - Medical Undersose ENS 522592016-09-22T07:00:00022 September 2016 07:00:00 Agreement State Agreement State Report - Patient Underdosage of Yttrium-90 2021-01-08T08:00:00 | |