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Start date | Reporting criterion | Title | Event description | System | LER | |
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ENS 56831 | 2 November 2023 07:00:00 | Agreement State | Y-90 Underdose | The following information was received via email: The Chief Physicist at Kaiser Permanente Medical Care Program of Southern California contacted the Radiologic Health Branch on November 2, 2023, at approximately 1757 PDT to report a medical event that occurred on the same day in Los Angeles, CA. The patient was underdosed during a radioembolization treatment for liver cancer that involved the administration of yttrium-90 (Y-90) TheraSpheres microspheres. The prescribed dose to the patient was 900 Gy, but the dose delivered to the patient was only 90.2 Gy due to a kink in the microcatheter used to deliver the Y-90. Kaiser Permanente will conduct an investigation to gain a better understanding of the details of the event. CA event ID number: 110323 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. |