ENS 52014: Difference between revisions
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StriderTol (talk | contribs) (Created page by program invented by StriderTol) |
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| event date = 06/16/2016 PDT | | event date = 06/16/2016 PDT | ||
| last update date = 07/07/2016 | | last update date = 07/07/2016 | ||
| title = Agreement State Report - Dose Administered | | title = Agreement State Report - Dose Administered to Wrong Patient | ||
| event text = The following information was received from the State of California via email: | | event text = The following information was received from the State of California via email: | ||
On June 16, 2016, [the] Radiation Safety Officer of the University of California, Los Angeles (UCLA), contacted the Brea office of the Radiologic Health Branch to report a medical event. The event resulted in a dose to the wrong patient that exceeded 20 percent of the prescribed dose (the dose that was likely to be given to another patient scheduled to be treated on June 17, 2016). The patient was given an activity of 4.02 GBq of Yttrium 90 (Nordion TheraSphere), resulting in a dose to the liver of 226.3 Gray. This dose exceeded the prescribed dose of 120 Gray. This activity was later discovered to be the activity that was most likely to have been ordered for a patient that was to be treated on June 17, 2016. The patient that was treated on June 16, 2016 has been notified. The investigation is ongoing to determine the cause of the event. | On June 16, 2016, [the] Radiation Safety Officer of the University of California, Los Angeles (UCLA), contacted the Brea office of the Radiologic Health Branch to report a medical event. The event resulted in a dose to the wrong patient that exceeded 20 percent of the prescribed dose (the dose that was likely to be given to another patient scheduled to be treated on June 17, 2016). The patient was given an activity of 4.02 GBq of Yttrium 90 (Nordion TheraSphere), resulting in a dose to the liver of 226.3 Gray. This dose exceeded the prescribed dose of 120 Gray. This activity was later discovered to be the activity that was most likely to have been ordered for a patient that was to be treated on June 17, 2016. The patient that was treated on June 16, 2016 has been notified. The investigation is ongoing to determine the cause of the event. | ||
Latest revision as of 21:44, 1 March 2018
| Where | |
|---|---|
| University Of California Los Angeles Los Angeles, California (NRC Region 4) | |
| License number: | 1335-19 |
| Organization: | California Radiation Control Prgm |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+29.1 h1.213 days <br />0.173 weeks <br />0.0399 months <br />) | |
| Opened: | Donelle Krajewski 12:06 Jun 17, 2016 |
| NRC Officer: | Steve Sandin |
| Last Updated: | Jul 7, 2016 |
| 52014 - NRC Website | |