ENS 52014
ENS Event | |
|---|---|
07:00 Jun 16, 2016 | |
| Title | Agreement State Report - Dose Administered to Wrong Patient |
| Event Description | The following information was received from the State of California via email:
On June 16, 2016, [the] Radiation Safety Officer of the University of California, Los Angeles (UCLA), contacted the Brea office of the Radiologic Health Branch to report a medical event. The event resulted in a dose to the wrong patient that exceeded 20 percent of the prescribed dose (the dose that was likely to be given to another patient scheduled to be treated on June 17, 2016). The patient was given an activity of 4.02 GBq of Yttrium 90 (Nordion TheraSphere), resulting in a dose to the liver of 226.3 Gray. This dose exceeded the prescribed dose of 120 Gray. This activity was later discovered to be the activity that was most likely to have been ordered for a patient that was to be treated on June 17, 2016. The patient that was treated on June 16, 2016 has been notified. The investigation is ongoing to determine the cause of the event. 5010 Number: 061616
This is a revision/update of EN #52014. On June 16, 2016, [the] Radiation Safety Officer of the University of California, Los Angeles (UCLA), contacted the Brea office of the Radiologic Health Branch to report a medical event. Two patients were scheduled to be treated with Nordion TheraSpheres containing yttrium 90, one on June 16 and the other on June 17. The first treatment occurred on June 16; however, the treatment dosage of 4.02 GBq (108.6 mCi) was approximately 1.9 times the prescribed dosage, apparently because the dosage for the second patient was given to the first patient. As a result, the first patient received a liver dose of 226.3 gray (22,630 rad) instead of the prescribed dose of 120 gray (12,000 rad). The patient has been notified, and the licensee is investigating to determine the cause of the event. Notified R4DO (Rollins) and NMSS Events Notification via email.
This is a revision/update of EN #52014. On 7/1/16 UCLA submitted a written report of this medical event. That report noted that in addition to the incorrect treatment dosage, the incorrect liver lobe was treated. As a result, the dose to the incorrect liver lobe was calculated as 328 Gy (32,800 rad). This differs from the previously reported liver dose of 226.3 Gy (22,630 rad) due to the difference in the sizes of the liver lobes. Notified R4DO (Drake) and NMSS Events Notification via email. 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 | |
|---|---|
| University Of California Los Angeles Los Angeles, California (NRC Region 4) | |
| License number: | 1335-19 |
| Organization: | California Radiation Control Prgm |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+29.1 h1.213 days <br />0.173 weeks <br />0.0399 months <br />) | |
| Opened: | Donelle Krajewski 12:06 Jun 17, 2016 |
| NRC Officer: | Steve Sandin |
| Last Updated: | Jul 7, 2016 |
| 52014 - NRC Website | |
University Of California Los Angeles with Agreement State | |
WEEKMONTHYEARENS 520142016-06-16T07:00:00016 June 2016 07:00:00
[Table view]Agreement State Agreement State Report - Dose Administered to Wrong Patient ENS 468712011-04-04T16:00:0004 April 2011 16:00:00 Agreement State Agreement State Report - Medical Event Misadministration of Prostate Seeds 2016-06-16T07:00:00 | |