ENS Event | |
|---|---|
07:00 Jul 20, 2021 | |
| Title | |
| Event Description | The following was received from the California Department of Public Health via email:
A medical event per 10 CFR 35.3045 was determined to have occurred on July 20, 2021, during a liver cancer therapy procedure using Y-90 Nordion TheraSpheres via manual brachytherapy under 10CFR35.1000. Dose 1: AU prescribed activity of 109.5 mCi of Y-90 to the patient's liver: right lobe segments 5 and 8 and successfully delivered 104 mCi (95 percent). Dose 2: AU prescribed 153.0 mCi of Y-90 to the patient's liver: right lobe segments 6 and 7, but could only deliver 68.5 mCi (44.8 percent). During the procedure, blockage occurred in the delivery apparatus, specifically the microcatheter, that the authorized user was unable to clear to complete the procedure. Pre and post-procedural vial measurements were performed using a calibrated ion chamber by a trained CNMT [Certified Nuclear Medicine Technologist] on July 20, 2021. 5010 Number: 072121 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 | |
|---|---|
| University Of California, San Diego La Jolla, California (NRC Region 4) | |
| License number: | 1339-37 |
| Organization: | California Radiation Control Prgm |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+34.35 h1.431 days <br />0.204 weeks <br />0.0471 months <br />) | |
| Opened: | Donald Oesterle 17:21 Jul 21, 2021 |
| NRC Officer: | Ossy Font |
| Last Updated: | Jul 21, 2021 |
| 55368 - NRC Website | |
University Of California, San Diego with Agreement State | |
WEEKMONTHYEARENS 558762022-05-03T07:00:0003 May 2022 07:00:00
[Table view]Agreement State Lost I-125 Brachytherapy Seeds ENS 553682021-07-20T07:00:00020 July 2021 07:00:00 Agreement State Y-90 Brachytherapy Underdose 2022-05-03T07:00:00 | |