ENS 55084

v t e ENS Event
08:00 Jan 25, 2021
Title	Incorrect Dose Delivered to Patient
Event Description	The following information was received from the state of California via email: On January 25, 2021, the Radiation Safety Officers [RSO] discovered and reported to CDPH [California Department of Public Health] that a medical event had occurred on December 28, 2020. The RSO stated that during a routine review of the past month's radiation therapies, they discovered that a Y-90 Nordion TheraSphere treatment performed on 12/28/2020 resulted in a delivered dose that was approximately 33 percent greater than the physician's written directive (550 Gy) signed on 12/15/2020. This higher patient dose was the result of administering the dose on Monday (12/28/2020) that was calibrated for administration on Tuesday (12/29/2020). The licensee will be submitting their 15 day report per 10 CFR 35.3045. California report no.: 012521 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 55084 +/-
Where
Loma Linda Medical Center Loma Linda, California (NRC Region 4)
License number:	0060-36
Organization:	California Radiation Control Prgm
Reporting

Agreement State
Time - Person (Reporting Time:+33.07 h1.378 days <br />0.197 weeks <br />0.0453 months <br />)
Opened:	Robert Greger 17:04 Jan 26, 2021
NRC Officer:	Brian Lin
Last Updated:	Jan 26, 2021
55084 - 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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