ENS 55060

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v t e ENS Event
08:00 Jan 8, 2021
Title	Underdose to Patient Undergoing Radiation Treatment
Event Description	The following information was received from the Radiologic Health Branch, California Department of Public Health via email: On Friday, January 8, 2021, the University of California Los Angeles (UCLA) notified the Radiologic Health Branch that a potential medical event involving Y-90 had occurred that day. A liver cancer patient was administered four vials of Y-90 BTG Nordion Inc. TheraSpheres to the patient's liver segments 4, 5, 6 and 7. Segment 4 was prescribed 120 Gy ( 0.86 GBq) and the delivered dose was 110.6 Gy (92.17%). Segment 5 was prescribed 120 Gy (0.86 GBq) and the delivered dose was 113.4 Gy (94.5%). Segment 6 was prescribed 120 Gy (0.86 GBq) and the delivered dose was 111.7 Gy (93.08%). Segment 7 was prescribed 120 Gy (0.86 GBq) and the delivered dose was 50.2 Gy (41.83%), which is less than 20 % of the prescribed amount. Overall, the average of the four administrations to the patient's liver was 80.4%. On January 10, 2021, the Radiologic Health Branch, sent an email to UCLA's Radiation Safety Officer requesting that UCLA's Environmental Health and Safety medical team perform an investigation to try to determine the root cause of the delivery failure for segment 7. They were asked to interview the authorized user and all other personnel attending the procedure and also to provide copies of the authorized user's written directives. The patient was notified of the under-dosage and potential continuation of their cancer treatment. 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.

ENS 55060 +/-
Where
Regents Of The 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:+78.25 h3.26 days <br />0.466 weeks <br />0.107 months <br />)
Opened:	Kathleen Harkness 14:15 Jan 11, 2021
NRC Officer:	Lloyd Desotell
Last Updated:	Jan 11, 2021
55060 - NRC Website
v • d • e

v t e Emergency Notification System
Regents Of The University Of California, Los Angeles with Agreement State
WEEKMONTHYEAR2021-01-08T08:00:00 [Table view]
[ENS list for Regents Of The University Of California, Los Angeles]

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