ENS 56940

v t e ENS Event
22:50 Jan 30, 2024
Title	Agreement State - Y-90 Underdose
Event Description	The following is a summary of information that was provided by the California Department of Public Health, Radiological Health Branch via email: On January 30, 2024, at 1450 PST, the radiation safety officer of Cedars Sinai Medical Center contacted the Los Angeles County Radiation Management office to report a medical underdose event. The underdose occurred during a treatment of Y-90 (yttrium-90) TheraSpheres microspheres for a radioembolization treatment for liver cancer. The prescribed activity was 480 Gy and the administered activity was 227.6 Gy (about 47 percent of the prescription). The underdose was due to an obstruction of the microcatheter used to deliver the Y-90. The patient has been notified. Cedars Sinai Medical Center will conduct an investigation to gain a better understanding of the details of the event. CA event ID number: 013024 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 56940 +/-
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:+-3.03 h-0.126 days <br />-0.018 weeks <br />-0.00415 months <br />)
Opened:	L. Robert Greger 19:48 Jan 30, 2024
NRC Officer:	Natalie Starfish
Last Updated:	Jan 30, 2024
56940 - 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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