ENS Event | |
|---|---|
22:15 Aug 5, 2024 | |
| Title | Medical Underdose |
| Event Description | The following report was received by the California Department of Public Health, Radiation Health Branch (RHB) via email:
The University of California, Los Angeles (UCLA) reported a medical event that had occurred on Monday, August 5, 2024, during a Y-90 Sirtex SIR-Sphere liver cancer treatment. The target organ was the patient's left liver lobe. The authorized user prescribed an activity of 0.71 GBq (19.14 mCi). Unfortunately, the target organ only received 7.72 mCi or 40.33 percent of the prescribed dose. The interventional radiologist reported that the cause of the under-delivery was a leak in the SIR-Sphere tubing system (delivery box and covered table). All contaminated equipment is being held for decay by UCLA. UCLA will submit a 15-day written report to the RHB. California Event Number: 080524 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 Ucla Los Angeles, California (NRC Region 4) | |
| License number: | 1335-19 |
| Organization: | California Radiation Control Prgm |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+23.25 h0.969 days <br />0.138 weeks <br />0.0318 months <br />) | |
| Opened: | Donald Oesterle 21:30 Aug 6, 2024 |
| NRC Officer: | Ian Howard |
| Last Updated: | Aug 6, 2024 |
| 57263 - NRC Website | |
Regents Of The Ucla with Agreement State | |
WEEKMONTHYEARENS 572632024-08-05T22:15:0005 August 2024 22:15:00
[Table view]Agreement State Medical Underdose 2024-08-05T22:15:00 | |