ENS 56831

v t e ENS Event
07:00 Nov 2, 2023
Title	Y-90 Underdose
Event Description	The following information was received via email: The Chief Physicist at Kaiser Permanente Medical Care Program of Southern California contacted the Radiologic Health Branch on November 2, 2023, at approximately 1757 PDT to report a medical event that occurred on the same day in Los Angeles, CA. The patient was underdosed during a radioembolization treatment for liver cancer that involved the administration of yttrium-90 (Y-90) TheraSpheres microspheres. The prescribed dose to the patient was 900 Gy, but the dose delivered to the patient was only 90.2 Gy due to a kink in the microcatheter used to deliver the Y-90. Kaiser Permanente will conduct an investigation to gain a better understanding of the details of the event. CA event ID number: 110323 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 56831 +/-
Where
Kaiser Permanente Med Care Program Pasadena, California (NRC Region 4)
License number:	0372-19
Organization:	California Radiation Control Prgm
Reporting

Agreement State
Time - Person (Reporting Time:+36.02 h1.501 days <br />0.214 weeks <br />0.0493 months <br />)
Opened:	Robert Greger 19:01 Nov 3, 2023
NRC Officer:	Donald Norwood
Last Updated:	Nov 3, 2023
56831 - NRC Website
v • d • e

v t e Emergency Notification System
Kaiser Permanente Med Care Program with Agreement State
WEEKMONTHYEAR2023-11-02T07:00:00 [Table view]
[ENS list for Kaiser Permanente Med Care Program]

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