ENS Event | |
|---|---|
08:00 Nov 19, 2021 | |
| Title | |
| Event Description | The following was received from the California Department of Public Health (CDPH) by email:
On Saturday, November 20, 2021, at 0928 [PST], a CDPH-Radiologic Health Branch inspector was notified by e-mail that a medical event had occurred on Friday, November 19, 2021, at UCLA during a Y-90 liver cancer treatment. There were four liver segments being treated with four vials of Y-90 TheraSpheres. The prescribed dose for 'Segment 2' was 120 Gy, but the dose delivered was 74.9 Gy (or 62.42 percent of the prescribed dose). Segments 3, 6 and 8 were prescribed 120 Gy each and the doses delivered were 108.0 Gy, 110.9 Gy and 107.0 Gy (90 percent, 92.42 percent and 89.17 percent of the prescribed doses, respectively). Using the post treatment radiation surveys of the Nalgene waste container, a UCLA medical physicist determined that a medical event had occurred. The delivered dose to the organ differed by more than 20 percent from the prescribed dose. The authorized physician tried unsuccessfully to use a 2.0 Fr Truselect microcatheter for an hour to access the artery to segment 2, but it was extraordinarily small in caliber. He eventually chose to use a 1.7 Fr Echelon microcatheter for the treatment. Other treatment options were considered, but this particular tumor was in a location that was not amenable to ablation or chemoembolization. The patient will have a follow-up MRI scan in 3 months. A 15-day written report will be generated by the UCLA." CA 5010 Number: 112021 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 | |
|---|---|
| Regents Of The University Of Ca-La Los Angeles, California (NRC Region 4) | |
| License number: | 1335-19 |
| Organization: | California Radiation Control Prgm |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+79.23 h3.301 days <br />0.472 weeks <br />0.109 months <br />) | |
| Opened: | Donald Oesterle 15:14 Nov 22, 2021 |
| NRC Officer: | Bethany Cecere |
| Last Updated: | Nov 22, 2021 |
| 55600 - NRC Website | |
Regents Of The University Of Ca-La with Agreement State | |
WEEKMONTHYEARENS 556002021-11-19T08:00:00019 November 2021 08:00:00
[Table view]Agreement State Y-90 Underdose 2021-11-19T08:00:00 | |