ENS Event | |
|---|---|
07:00 Apr 11, 2022 | |
| Title | Patient Received Dose Greater than Prescribed |
| Event Description | The following was received from the State of California, Department of Public Health, Radiologic Health Branch, via email:
The Radiologic Health Branch was notified on April 12, 2022 regarding a medical event that occurred on April 11, 2022 at Loma Linda University Health. An authorized user was performing Y-90 brachytherapy using Nordion TheraSpheres on a patient's liver. After catheterizing and delivering Y-90 to the first segment, it was discovered that due to the patient's variant anatomy, the segment had been misidentified. The written directive called for 2.228 GBq to deliver 950 Gy to the patient's liver segment 7. However, post treatment analysis of the source vial determined that 2.840 GBq (76.7 mCi) was delivered. As a result, the dose delivered to that segment was approximately 27 percent above the dose specified in the written directive. A 15-day report will be generated by the licensee per 10 CFR 35.3045. California Event Number: 041222 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 | |
|---|---|
| Loma Linda University Health Loma Linda, California (NRC Region 4) | |
| License number: | 0060-36 |
| Organization: | California Radiation Control Prgm |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+36.78 h1.533 days <br />0.219 weeks <br />0.0504 months <br />) | |
| Opened: | Donald Oesterle 19:47 Apr 12, 2022 |
| NRC Officer: | Mike Stafford |
| Last Updated: | Apr 12, 2022 |
| 55840 - NRC Website | |
Loma Linda University Health with Agreement State | |
WEEKMONTHYEARENS 558402022-04-11T07:00:00011 April 2022 07:00:00
[Table view]Agreement State Patient Received Dose Greater than Prescribed ENS 558302022-04-06T07:00:0006 April 2022 07:00:00 Agreement State Overdose to Patient 2022-04-06T07:00:00 | |