ENS Event | |
|---|---|
07:00 Sep 12, 2022 | |
| Title | |
| Event Description | The following was submitted by the California Department of Public Health by email:
On Sept. 12, 2022, the RSO of Cedars Sinai Medical Center (CSMC) contacted Los Angeles County Public Health, Radiation Management (LA County) to report a medical event that ocurred at CSMC. During administraton of Y-90 Theraspheres to a patient, the Y-90 spheres were stuck in the microcatheter and the Authorized User (AU) was unable to administer the full dosage. The dosage drawn in the syringe was approximately 1.77 GBq (48 mCi) but only 1.05 GBq (28 mCi) was administered, a residual dosage of 40.7 percent [not administered]. Additionally, the prescribed dose to the target organ, liver, was 124 Gy (12,400 rad). The liver received a dose of approximately 71 Gy (7,100 rad), a difference of 5.3 Gy (5,300 rad). The RSO has initiated an investigation and the AU will be providing a detailed report. California Reference Number: 091222 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 | |
|---|---|
| Cedars Sinai Medical Center Los Angeles, California (NRC Region 4) | |
| License number: | 0404-19 |
| Organization: | California Radiation Control Prgm |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+-0.57 h-0.0238 days <br />-0.00339 weeks <br />-7.80786e-4 months <br />) | |
| Opened: | Joji Ortego 06:26 Sep 12, 2022 |
| NRC Officer: | Ernest West |
| Last Updated: | Sep 12, 2022 |
| 56104 - NRC Website | |
Cedars Sinai Medical Center with Agreement State | |
WEEKMONTHYEARENS 569402024-01-30T22:50:00030 January 2024 22:50:00
[Table view]Agreement State Agreement State - Y-90 Underdose ENS 561042022-09-12T07:00:00012 September 2022 07:00:00 Agreement State Underdose of Y-90 Microspheres ENS 506472014-11-07T08:00:0007 November 2014 08:00:00 Agreement State Agreement State - Medical Event Involving Underdosage to Patient of Y-90 Sir-Spheres ENS 500912014-04-30T07:00:00030 April 2014 07:00:00 Agreement State Agreement State Report - Incorrect Dosage Administered to Patient 2024-01-30T22:50:00 | |