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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 56860 | 15 November 2023 08:00:00 | Agreement State | IODINE-131 Overdose | The following information was provided by the California Department of Public Health (CDPH) via email: On November 15, 2023, at 2107 PST, (DELETED), the radiation safety officer (RSO) at City of Hope, reported by email that a patient scheduled to receive an oral administration of 100 mCi (millicuries) of iodine-131 (I-131) was instead orally administered 160 mCi of I-131, an excess of 60 mCi. On November 16, 2023, the RSO calculated that the difference in the prescribed dose to the thyroid (target organ) was 488 rem, and that the difference in the prescribed dose to the whole body effective-dose-equivalent was 62 rem. The licensee will be submitting a 15-day written report with additional details. The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: No patient intervention was reported immediately but may be reported in the 15-day report. The excess activity of 60 mCi and dose of 488 rem will result in a dose to the patient that exceeds the original prescribed dose by more than 50 percent. 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 55892 | 10 May 2022 07:00:00 | Agreement State | Underdose Medical Event | The following information was received via e-mail: The City of Hope Radiation Safety Officer contacted LA County Radiation Management (LA County) on May 10, 2022 to report a Medical Event that occurred on the same day at City of Hope in Duarte, CA. The patient was underdosed during a Selective Internal Radiation Therapy (SIRT) treatment for liver cancer that involved the administration of SIR-Spheres yttrium-90 (Y-90) resin microspheres. The prescribed dose to the patient was 10 mCi, but the dose delivered to the patient was only 6.42 mCi due to a leakage caused by a loose tubing connection. City of Hope will conduct an investigation to gain a better understanding of the details of the event." California 5010 Number: 051022 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 55603 | 20 November 2021 03:45:00 | Agreement State | Underdose of Patient | The following was a summary of an e-mail received by the state of California's Radiation Health Branch (RHB): The Radiation Safety Officer (RSO) at the licensee facility contacted the RHB and Los Angeles County Radiation Management (L.A. County) on November 22, 2021, to report a medical event. The event occurred on November 19, 2021. According to the RSO, a patient, who was part of a clinical trial, was under-dosed during a therapeutic treatment procedure for prostate cancer that involved the injection of actinium 225 (Ac-225) in the peripheral vein. The prescribed dose to the patient was 150 microcuries; however, the dose delivered was only 114 microcuries due to an accidental discharge of the radioisotope on the chux pad before it was administered to the patient. There was no spread of contamination. A site visit will be conducted to gain a better understanding of the details of the event. California Event Number: 112221 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 43493 | 16 July 2007 05:00:00 | Agreement State | Agreement State Report - Unplanned Exposure During Calibration Test | The State provided the following information via facsimile: A doctor was performing a monthly calibration test and position verification test. During the test, an error message was received using a dummy source. The doctor entered the room with a survey meter which showed no elevated radiation reading. The emergency handwheel was used to retract the dummy wire. After about 12 turns, the room radiation alarms initiated and the doctor left the room. Troubleshooting disclosed that the source had become exposed and the doctor received approximately 75 Mr exposure. Source: Ir-192, 5.2 Curies Varian Medical Systems model Varisource HDR |