ENS Event | |
|---|---|
07:00 May 10, 2022 | |
| Title | Underdose Medical Event |
| Event Description | The following information was received via e-mail:
The City of Hope Radiation Safety Officer contacted LA County Radiation Management (LA County) on May 10, 2022 to report a Medical Event that occurred on the same day at City of Hope in Duarte, CA. The patient was underdosed during a Selective Internal Radiation Therapy (SIRT) treatment for liver cancer that involved the administration of SIR-Spheres yttrium-90 (Y-90) resin microspheres. The prescribed dose to the patient was 10 mCi, but the dose delivered to the patient was only 6.42 mCi due to a leakage caused by a loose tubing connection. City of Hope will conduct an investigation to gain a better understanding of the details of the event." California 5010 Number: 051022 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 | |
|---|---|
| City Of Hope Duarte, California (NRC Region 4) | |
| License number: | 0307-19 |
| Organization: | California Radiation Control Prgm |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+16.95 h0.706 days <br />0.101 weeks <br />0.0232 months <br />) | |
| Opened: | Robert Greger 23:57 May 10, 2022 |
| NRC Officer: | Donald Norwood |
| Last Updated: | May 11, 2022 |
| 55892 - NRC Website | |
City Of Hope with Agreement State | |
WEEKMONTHYEARENS 568602023-11-15T08:00:00015 November 2023 08:00:00
[Table view]Agreement State IODINE-131 Overdose ENS 558922022-05-10T07:00:00010 May 2022 07:00:00 Agreement State Underdose Medical Event ENS 556032021-11-20T03:45:00020 November 2021 03:45:00 Agreement State Underdose of Patient ENS 434932007-07-16T05:00:00016 July 2007 05:00:00 Agreement State Agreement State Report - Unplanned Exposure During Calibration Test 2023-11-15T08:00:00 | |