ENS 56104

v t e ENS Event
07:00 Sep 12, 2022
Title	Underdose of Y-90 Microspheres
Event Description	The following was submitted by the California Department of Public Health by email: On Sept. 12, 2022, the RSO of Cedars Sinai Medical Center (CSMC) contacted Los Angeles County Public Health, Radiation Management (LA County) to report a medical event that ocurred at CSMC. During administraton of Y-90 Theraspheres to a patient, the Y-90 spheres were stuck in the microcatheter and the Authorized User (AU) was unable to administer the full dosage. The dosage drawn in the syringe was approximately 1.77 GBq (48 mCi) but only 1.05 GBq (28 mCi) was administered, a residual dosage of 40.7 percent [not administered]. Additionally, the prescribed dose to the target organ, liver, was 124 Gy (12,400 rad). The liver received a dose of approximately 71 Gy (7,100 rad), a difference of 5.3 Gy (5,300 rad). The RSO has initiated an investigation and the AU will be providing a detailed report. California Reference Number: 091222 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 56104 +/-
Where
Cedars Sinai Medical Center Los Angeles, California (NRC Region 4)
License number:	0404-19
Organization:	California Radiation Control Prgm
Reporting

Agreement State
Time - Person (Reporting Time:+-0.57 h-0.0238 days <br />-0.00339 weeks <br />-7.80786e-4 months <br />)
Opened:	Joji Ortego 06:26 Sep 12, 2022
NRC Officer:	Ernest West
Last Updated:	Sep 12, 2022
56104 - NRC Website
v • d • e

v t e Emergency Notification System
Cedars Sinai Medical Center with Agreement State
WEEKMONTHYEAR2024-01-30T22:50:00 [Table view]
[ENS list for Cedars Sinai Medical Center]

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