ENS Event | |
|---|---|
02:41 Jan 21, 2026 | |
| Title | Medical Event |
| Event Description | The following information was provided by the California Radiation Control Program, Radiologic Health Branch (RHB), via email:
On January 20, 2026, at approximately 1841 PST, the radiation safety officer and Associate Director of Environmental Health & Safety at Cedars Sinai Medical Center contacted RHB to report a medical event that occurred earlier that same day. The event involved an underdose to a patient during a radioembolization treatment for liver cancer using yttrium-90 (Y-90) TheraSphere microspheres. The prescribed activity was 3.01 GBq. Approximately 88.5 percent of the activity remained as residual activity [in the administration kit] due to a kink in the microcatheter used for delivery of the Y-90 microspheres. Cedars Sinai Medical Center will investigate to gain a better understanding of the details of the event. RHB will also investigate the medical event, to include the licensee's investigation results. California 5010 number: 012026 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 | |
|---|---|
| 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:+15.77 h0.657 days <br />0.0939 weeks <br />0.0216 months <br />) | |
| Opened: | Jeff Day 18:27 Jan 21, 2026 |
| NRC Officer: | Karen Cotton |
| Last Updated: | Jan 21, 2026 |
| 58125 - 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 | |