ENS 55351

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v t e ENS Event
07:00 Jul 9, 2021
Title	Medical Underdose
Event Description	The following was received from the state of California via e-mail: On Monday, July 12, 2021, [Radiation Health Branch] (RHB) Licensing Unit forwarded a July 9, 2021 email from [Radiation Safety Officer] (RSO) [redacted] (Permanente Medical Group, RML # 0269) stating that a patient received only half of the intended dosage for a Y-90 procedure of the liver. RHB contacted the RSO [redacted] for additional information on July 12, 2021. The RSO [redacted] emailed a statement from the Authorized User (AU), Interventional Radiologist, [redacted], stating that a Therasphere procedure was performed on Friday, July 9, 2021 that called for a prescribed dosage of 2.876 GBq of Y-90 Theraspheres. Prior to administration of the Y-90, the catheter was flushed with saline. AU reported that a slight resistance was felt, but all of the flush went through the catheter. He attributed the resistance to the sharp turns of the catheter in the branch vessel. The administration of 2.876 GBq Y-90 Therasphere was started. Upon administration of the Y-90 Theraspheres, the resistance became appreciated. Administration of the Y-90 Theraspheres was stopped and the catheter was withdrawn. Subsequent Geiger counter examination of the removed catheter indicated greater than normal activity remained. AU later confirmed that of the 2.876 GBq prescribed dosage, only 47.6 percent was delivered. 1.34 GBq Y-90 went to the liver and 0.027 GBq went to the lung. The resulting dose was 162.8 Gy to the liver and 1.37 Gy to the lungs. A written report will be provided to RHB within two weeks. CA Incident No.: 070921 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 55351 +/-
Where
Permanente Medical Group, Inc. San Francisco, California (NRC Region 4)
License number:	0269-38
Organization:	California Radiation Control Prgm
Reporting

Agreement State
Time - Person (Reporting Time:+83.22 h3.468 days <br />0.495 weeks <br />0.114 months <br />)
Opened:	K. Arunika Hewadikaram 18:13 Jul 12, 2021
NRC Officer:	Joanna Bridge
Last Updated:	Jul 12, 2021
55351 - NRC Website
v • d • e

v t e Emergency Notification System
Permanente Medical Group, Inc. with Agreement State
WEEKMONTHYEAR2021-07-09T07:00:00 [Table view]
[ENS list for Permanente Medical Group, Inc.]

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