ENS 55579

v t e ENS Event
08:00 Nov 12, 2021
Title	Underdose During Y-90 Administration
Event Description	The following information was received via E-mail: On Saturday, November 13, 2021 at 1420 PST, a CDPH-Radiologic Health Branch inspector was notified by E-mail that a medical event had occurred on November 12, 2021, at UCLA during a Y-90 liver cancer treatment. The signed written directive was included in the notification. The prescribed dose for 'Segment Left' was 70 Gy (6 GBq) and the dose delivered was 68.8 Gy (or 98.29 percent of the prescribed dose). The prescribed dose for 'Segment Right' was 120 Gy (3 GBq) and the dose delivered was 78.3 Gy (or 65.25 percent of the prescribed dose). The authorized user administered two vials of BTG Nordion Inc. TheraSphere Y-90 glass microspheres beginning approximately 1200 PST. Vial number 101 went to the right lobe and vial number 30 went to the left lobe of the liver. Radiation surveys of the waste containers occurred at 1516 PST and 1519 PST respectively, and the radiation level from vial number 30 was higher than expected. UCLA's medical physicist was consulted at 1630 PST November 12, 2021, who determined that a medical event had occurred. UCLA will be investigating the cause of the underdose and make a 15-day written report. California 5010 Number: 111221 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 55579 +/-
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:+79.2 h3.3 days <br />0.471 weeks <br />0.108 months <br />)
Opened:	Donald Oesterle 15:12 Nov 15, 2021
NRC Officer:	Donald Norwood
Last Updated:	Nov 15, 2021
55579 - NRC Website
v • d • e

v t e Emergency Notification System
Regents Of The University Of California - Los Angeles with Agreement State
WEEKMONTHYEAR2021-11-12T08:00:00 [Table view]
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