ENS 55603

v t e ENS Event
03:45 Nov 20, 2021
Title	Underdose of Patient
Event Description	The following was a summary of an e-mail received by the state of California's Radiation Health Branch (RHB): The Radiation Safety Officer (RSO) at the licensee facility contacted the RHB and Los Angeles County Radiation Management (L.A. County) on November 22, 2021, to report a medical event. The event occurred on November 19, 2021. According to the RSO, a patient, who was part of a clinical trial, was under-dosed during a therapeutic treatment procedure for prostate cancer that involved the injection of actinium 225 (Ac-225) in the peripheral vein. The prescribed dose to the patient was 150 microcuries; however, the dose delivered was only 114 microcuries due to an accidental discharge of the radioisotope on the chux pad before it was administered to the patient. There was no spread of contamination. A site visit will be conducted to gain a better understanding of the details of the event. California Event Number: 112221 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 55603 +/-
Where
City Of Hope Duarte, California (NRC Region 4)
License number:	0307-19
Organization:	California Radiation Control Prgm
Reporting

Agreement State
Time - Person (Reporting Time:+87.97 h3.665 days <br />0.524 weeks <br />0.121 months <br />)
Opened:	Ana Casaje 19:43 Nov 23, 2021
NRC Officer:	Brian P. Smith
Last Updated:	Nov 23, 2021
55603 - NRC Website
v • d • e

v t e Emergency Notification System
City Of Hope with Agreement State
WEEKMONTHYEAR2023-11-15T08:00:00 [Table view]
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