ENS Event | |
|---|---|
08:00 Jan 25, 2021 | |
| Title | Incorrect Dose Delivered to Patient |
| Event Description | The following information was received from the state of California via email:
On January 25, 2021, the Radiation Safety Officers [RSO] discovered and reported to CDPH [California Department of Public Health] that a medical event had occurred on December 28, 2020. The RSO stated that during a routine review of the past month's radiation therapies, they discovered that a Y-90 Nordion TheraSphere treatment performed on 12/28/2020 resulted in a delivered dose that was approximately 33 percent greater than the physician's written directive (550 Gy) signed on 12/15/2020. This higher patient dose was the result of administering the dose on Monday (12/28/2020) that was calibrated for administration on Tuesday (12/29/2020). The licensee will be submitting their 15 day report per 10 CFR 35.3045. California report no.: 012521 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 | |
|---|---|
| Loma Linda Medical Center Loma Linda, California (NRC Region 4) | |
| License number: | 0060-36 |
| Organization: | California Radiation Control Prgm |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+33.07 h1.378 days <br />0.197 weeks <br />0.0453 months <br />) | |
| Opened: | Robert Greger 17:04 Jan 26, 2021 |
| NRC Officer: | Brian Lin |
| Last Updated: | Jan 26, 2021 |
| 55084 - NRC Website | |
Loma Linda Medical Center with Agreement State | |
WEEKMONTHYEARENS 550842021-01-25T08:00:00025 January 2021 08:00:00
[Table view]Agreement State Incorrect Dose Delivered to Patient ENS 528902017-08-04T07:00:0004 August 2017 07:00:00 Agreement State Agreement State Report - Y-90 Treatment Underdose ENS 519732016-05-27T07:00:00027 May 2016 07:00:00 Agreement State Agreement State Report - Brachytherapy Underdose ENS 483892012-05-23T07:00:00023 May 2012 07:00:00 Agreement State Agreement State Report - Potential Medical Event ENS 405942004-03-16T08:00:00016 March 2004 08:00:00 Agreement State Agreement State Report - Missing Sr-90 Eye Applicator Source 2021-01-25T08:00:00 | |