ENS Event | |
|---|---|
22:03 Oct 16, 2020 | |
| Title | Agreement State Report - Greater than Intended Dose to Liver Lobe |
| Event Description | The following was received via email from the California Radiation Control Program:
On October 16, 2020, the [Radiation Safety Officer] RSO of Stanford University emailed [the Radiation Health Branch] RHB to inform a medical event with a Y-90 patient treatment. The physician mistakenly delivered the larger dose (approximately 30 mCi) to the liver lobe that was to get the smaller dose (approximately 13 mCi). The dose to the second lobe was adjusted with left over Y-90 from the dose draw to give the proper dose to the other lobe (approximately 30 mCi). So one lobe received much greater than the intended dose, while the other lobe received the proper dose. RHB will follow up on this investigation. California 5010 Number: 101620 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 Board Of Trustees Of The Leland Stanford, Jr. University Stanford, California (NRC Region 4) | |
| License number: | 0676-43 |
| Organization: | California Radiation Control Prgm |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+-1.43 h-0.0596 days <br />-0.00851 weeks <br />-0.00196 months <br />) | |
| Opened: | K. Arunika Hewadikaram 20:37 Oct 16, 2020 |
| NRC Officer: | Brian P. Smith |
| Last Updated: | Oct 16, 2020 |
| 54953 - NRC Website | |
The Board Of Trustees Of The Leland Stanford, Jr. University with Agreement State | |
WEEKMONTHYEARENS 549532020-10-16T22:03:00016 October 2020 22:03:00
[Table view]Agreement State Greater than Intended Dose to Liver Lobe 2020-10-16T22:03:00 | |