ENS 55334

v t e ENS Event
07:00 Jul 1, 2021
Title	Patient Under Dose
Event Description	The following was submitted by the California Department of Public Health - Radiologic Health Branch (RHB) by email: On 07/01/2021, licensee contacted RHB to report a medical event associated with Ytrrium-90 TheraSpheres. On the written directive, Authorized User's (AU) desired dose to the target volume was 800 Gy. Based on the calculations, radiation dose delivered was 400.2 Gy. During the procedure, patient was infused with 1.067 Gbq of Y-90. Upon completion of the infusion, based on residual exposure readings, it was determined that an estimated dose of 0.522 Gbq was delivered to the patient, 50% of the written directive. Given the Y-90 supply vial was empty, based on the 0.00 mR/hr reading on the adjacent dosimeter, it has been speculated that Y-90 was held up in the micro-catheter. AU suspects this high residual waste reading was due to a slower infusion of the treatment dose and flushing fluid; this will be determined at a later date when the yttrium-90 waste material has decayed and can be safely broken down with individual components measured. The referring physician (AU), informed the patient of the event. RHB will be following up on the medical event. CA 5010 Number: 070121 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 55334 +/-
Where
John Muir Medical Center Concord, California (NRC Region 4)
License number:	0729-07
Organization:	California Radiation Control Prgm
Reporting

Agreement State
Time - Person (Reporting Time:+13.28 h0.553 days <br />0.079 weeks <br />0.0182 months <br />)
Opened:	K. Arunika Hewadikaram 20:17 Jul 1, 2021
NRC Officer:	Bethany Cecere
Last Updated:	Jul 1, 2021
55334 - NRC Website
v • d • e

v t e Emergency Notification System
John Muir Medical Center with Agreement State
WEEKMONTHYEAR2021-07-01T07:00:00 [Table view]
[ENS list for John Muir Medical Center]

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