ENS Event | |
|---|---|
07:00 Jul 26, 2024 | |
| Title | Dose to Unintended Organ |
| Event Description | The following information was obtained from the California Department of Public Health, Radiologic Health Branch, via email:
University of California at Los Angeles (UCLA) reported a medical event had occurred on Friday, July 26, 2024, during a Y-90 Therasphere liver cancer treatment. Patient SPECT imaging performed on August 1, 2024, showed that all of the Y-90 activity was in the patient's stomach tissue rather than in the intended left lobe of the liver. The licensee reported that the dosage of Y-90 administered was in conformance with the written directive. UCLA is continuing to investigate to determine how the Y-90 Theraspheres ended up in the stomach tissue and will address the cause in their 15-day written report to the Radiologic Health Branch. Per the licensee's documentation, a dosage of 0.77 GBq was delivered to the patient, with 0.74 GBq expected to go to the treatment site to result in a dose of 178.9 Gy to the treatment site. California event number: 5010-080124 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 | |
|---|---|
| Regents Of The University Of California- Los Angeles Los Angeles, California (NRC Region 4) | |
| License number: | 1335-19 |
| Organization: | California Dept Of Public Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+176.35 h7.348 days <br />1.05 weeks <br />0.242 months <br />) | |
| Opened: | Robert Greger 15:21 Aug 2, 2024 |
| NRC Officer: | Robert A. Thompson |
| Last Updated: | Aug 2, 2024 |
| 57261 - NRC Website | |
Regents Of The University Of California- Los Angeles with Agreement State | |
WEEKMONTHYEARENS 572612024-07-26T07:00:00026 July 2024 07:00:00
[Table view]Agreement State Dose to Unintended Organ 2024-07-26T07:00:00 | |