ENS Event | |
|---|---|
07:00 Jul 1, 2021 | |
| Title | Patient Under Dose |
| Event Description | The following was submitted by the California Department of Public Health - Radiologic Health Branch (RHB) by email:
On 07/01/2021, licensee contacted RHB to report a medical event associated with Ytrrium-90 TheraSpheres. On the written directive, Authorized User's (AU) desired dose to the target volume was 800 Gy. Based on the calculations, radiation dose delivered was 400.2 Gy. During the procedure, patient was infused with 1.067 Gbq of Y-90. Upon completion of the infusion, based on residual exposure readings, it was determined that an estimated dose of 0.522 Gbq was delivered to the patient, 50% of the written directive. Given the Y-90 supply vial was empty, based on the 0.00 mR/hr reading on the adjacent dosimeter, it has been speculated that Y-90 was held up in the micro-catheter. AU suspects this high residual waste reading was due to a slower infusion of the treatment dose and flushing fluid; this will be determined at a later date when the yttrium-90 waste material has decayed and can be safely broken down with individual components measured. The referring physician (AU), informed the patient of the event. RHB will be following up on the medical event. CA 5010 Number: 070121 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 | |
|---|---|
| John Muir Medical Center Concord, California (NRC Region 4) | |
| License number: | 0729-07 |
| Organization: | California Radiation Control Prgm |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+13.28 h0.553 days <br />0.079 weeks <br />0.0182 months <br />) | |
| Opened: | K. Arunika Hewadikaram 20:17 Jul 1, 2021 |
| NRC Officer: | Bethany Cecere |
| Last Updated: | Jul 1, 2021 |
| 55334 - NRC Website | |
John Muir Medical Center with Agreement State | |
WEEKMONTHYEARENS 553342021-07-01T07:00:0001 July 2021 07:00:00
[Table view]Agreement State Patient Under Dose 2021-07-01T07:00:00 | |