ENS 57263

v t e 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.

ENS 57263 +/-
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
v • d • e

v t e Emergency Notification System
Regents Of The Ucla with Agreement State
WEEKMONTHYEAR2024-08-05T22:15:00 [Table view]
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