The following was received from the State of
California, Department of Public Health (
RHB), via email:
On April 6, 2022, Loma Linda University Health's (LLUH) Radiation Safety Officer was notified by a medical authorized user that a reportable medical event had occurred during a Y-90 Therasphere patient brachytherapy treatment on April 5, 2022.
There were two patients scheduled for brachytherapy on the same day. Patient 1 had two tailored dose vials of Y-90 and Patient 2 had three tailored dose vials of Y-90 stored in the hot lab. A certified nuclear medical technologist mistakenly selected one of Patient 2's vials for Patient 1's treatment. The selected vial contained 4.0 GBq (108 milliCuries) with calibration date April 3, 2022 at 1200 PDT. It contained approximately 58.6 milliCuries at the time of administration.
The two vials were taken to the therapy suite, where they were approved and used by the authorized user. The authorized user's written directive for Patient 1's liver segments 2 and 3 was to deliver a dose of 120 Gy. However, the mistake resulted in a dose of 750 Gy to the two liver segments. If the proper vial had been selected, the administered activity would have been 9.6 milliCuries.
The error also resulted in the cancellation of Patient 2's treatment, as the Y-90 dose was no longer available. LLUH will be submitting a 15-day report to RHB. Abnormal Occurrence criteria for Medical Event's: Unplanned dose greater than or equal to 1000 rad to any other organ AND dose is greater than 150 percent of the prescribed dose."
California Event Number: 040622
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.