ENS Event | |
|---|---|
08:00 Nov 7, 2014 | |
| Title | Agreement State - Medical Event Involving Underdosage to Patient of Y-90 Sir-Spheres |
| Event Description | The following is a synopsis of information received via E-mail:
The Cedars Sinai Medical Center (CSMC) Radiation Physics Manager (RPM) contacted Los Angeles County Radiation Management (LA County) via telephone to report a potential medical event that had occurred at CSMC. The RPM stated that the event resulted from a dosage administration to the patient of yttrium-90 SIR-Spheres less than that prescribed. LA County requested that a written report be submitted. Per the written report, the treatment plan required administration of 31 milliCuries (mCi) of Y-90 through a catheter via the hepatic artery. During setup, the interventional radiologist (IR) noted a potential air bubble in one of the lines connected to the catheter. The IR disconnected the line and flushed it with solution to clear the air bubble. The IR then activated the SIR-Sphere device without realizing that the line was still disconnected from the catheter. The radioactive material spilled into the sterile 4 inch by 4 inch gauze and drapes on the sterile field. The patient received 13 mCi, which was 42 percent of the prescribed dosage of 31 mCi. The RPM stated that the referring physician and patient were notified and that the patient did not report any side effects as a result of the incorrect dosage administration. Based on CSMC's written report, it was determined that this event required 24-hr notification to the NRC Operations Center. 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:+609.25 h25.385 days <br />3.626 weeks <br />0.835 months <br />) | |
| Opened: | Josephine Ortego 17:15 Dec 2, 2014 |
| NRC Officer: | Donald Norwood |
| Last Updated: | Dec 2, 2014 |
| 50647 - 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 | |