ENS Event | |
|---|---|
08:00 Oct 30, 2025 | |
| Title | Medical Event |
| Event Description | The following information was provided by the California Department of Public Health, Radiologic Health Branch (RHB) via email:
On 10/30/25, the licensee was treating a patient with Y-90 microspheres to a liver lobe in 3 dosages. The first two dosages were successfully administered, but the third dosage did not deliver successfully, with essentially none of the dosage reaching the target. Instead, the majority of the dosage was retained in the administration apparatus with some having leaked out, resulting in contamination of the treatment room and treating personnel. While the licensee reported this event to RHB on 11/1/25, it was reported by email and not directed to the correct RHB sub-organization, nor was the email clear regarding the event. This resulted in the significant delay in reporting this event to the NRC. RHB is still investigating this event. California 5010 Number: 110125 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 | |
|---|---|
| The Regents Of University Of Ca Sacramento, California (NRC Region 4) | |
| License number: | 1334-57 |
| Organization: | California Radiation Control Prgm |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+532.63 h22.193 days <br />3.17 weeks <br />0.73 months <br />) | |
| Opened: | Davood Aboudarda 13:38 Nov 21, 2025 |
| NRC Officer: | Ernest West |
| Last Updated: | Nov 21, 2025 |
| 58053 - NRC Website | |
The Regents Of University Of Ca with Agreement State | |
WEEKMONTHYEARENS 580532025-10-30T08:00:00030 October 2025 08:00:00
[Table view]Agreement State Medical Event 2025-10-30T08:00:00 | |