ENS Event | |
|---|---|
08:00 Feb 27, 2025 | |
| Title | Medical Event |
| Event Description | The following information was provided by the California Department of Public Health, Radiologic Health Branch, via email:
On February 28, 2025, the radiation safety officer (RSO) at Keck Hospital of University of Southern California, contacted the Los Angeles County Radiation Management office to report a possible medical event that occurred on February 27, 2025, during a Y-90 Therasphere radioembolization treatment of a liver cancer patient. The RSO indicated that due to abnormally high readings from the waste container associated with one of two dosage vials, he was unable to confirm the dosage administered to the patient. He sent the waste container to the vendor, Boston Scientific, for evaluation, in order to determine the administered dosage. On March 3, 2025, [the RSO] reported via e-mail that the patient was prescribed a total dose of 1300 Gy, but only 695.5 Gy was delivered during the treatment, which was attributed to the dosage from one of two dosage vials being stuck in the tubing. The underdosage meets the criteria for a reportable medical event. The incident did not cause any harm to the patient. Further analysis will be conducted by Boston Scientific to determine the reason for the dosage being stuck in the tubing. CA Event Number: 022825 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 | |
|---|---|
| Keck Hospital Of Usc Los Angeles, California (NRC Region 4) | |
| License number: | 5592-19 |
| Organization: | California Radiation Control Prgm |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+119.63 h4.985 days <br />0.712 weeks <br />0.164 months <br />) | |
| Opened: | L. Robert Greger 07:38 Mar 4, 2025 |
| NRC Officer: | Adam Koziol |
| Last Updated: | Mar 4, 2025 |
| 57584 - NRC Website | |
Keck Hospital Of Usc with Agreement State | |
WEEKMONTHYEARENS 575842025-02-27T08:00:00027 February 2025 08:00:00
[Table view]Agreement State Medical Event 2025-02-27T08:00:00 | |