ENS Event | |
|---|---|
07:00 Apr 14, 2025 | |
| Title | Medical Event |
| Event Description | The following report was received by the California Radiation Control Program via email:
On April 15, 2025, the radiation safety officer at Cedars Sinai Medical Center contacted Los Angeles County Public Health Radiation Management (part of the California Radiation Control Program), first by telephone at 0955 PDT and then by email at 1055 PDT, to report a medical event that occurred at Cedars Sinai Medical Center. During the administration of Y-90 TheraSpheres to a patient, the Y-90 TheraSpheres became obstructed within the intravenous tubing such that the authorized user was unable to administer the full dosage. The activity in the syringe was approximately 35 mCi, but only 12.14 mCi was delivered to the target organ. This was 35 percent of the prescribed activity. Additionally, the prescribed dose to the liver (the target organ) was 78.8 gray [7,880 rads]. The liver received a dose of 27.6 gray [2,760 rads], a difference of 51.2 gray [5,120 rads]. A site visit by the principal radiation protection specialist, Los Angeles County Public Health Radiation Management is scheduled for April 17, 2025." 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. California 5010 Number: 041525 |
| 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:+54.95 h2.29 days <br />0.327 weeks <br />0.0753 months <br />) | |
| Opened: | Thomas Miko 13:57 Apr 16, 2025 |
| NRC Officer: | Brian P. Smith |
| Last Updated: | Apr 16, 2025 |
| 57668 - NRC Website | |
Cedars Sinai Medical Center with Agreement State | |
WEEKMONTHYEARENS 581252026-01-21T02:41:00021 January 2026 02:41:00
[Table view]Agreement State Medical Event ENS 576682025-04-14T07:00:00014 April 2025 07:00:00 Agreement State Medical Event ENS 569402024-01-30T22:50:00030 January 2024 22:50:00 Agreement State Agreement State - Y-90 Underdose ENS 561042022-09-12T07:00:00012 September 2022 07:00:00 Agreement State Underdose of Y-90 Microspheres ENS 506472014-11-07T08:00:0007 November 2014 08:00:00 Agreement State Agreement State - Medical Event Involving Underdosage to Patient of Y-90 Sir-Spheres ENS 500912014-04-30T07:00:00030 April 2014 07:00:00 Agreement State Agreement State Report - Incorrect Dosage Administered to Patient 2026-01-21T02:41:00 | |