ENS 53344

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v t e ENS Event
07:00 Mar 30, 2018
Title	Misadministration of Sir-Spheres Y-90 Microspheres Resulting in an Underdose
Event Description	The following was received from the State of Washington via email: Patient was under treated with Y-90 SIR-Spheres Microspheres. Prescribed dose was 24.59 mCi. Patient was treated with 8.9 mCi. Background: SIR-Spheres Microspheres Activity Calculator determined a treatment dose of 0.91 GBq (24.59 mCi). Written Directive was signed for 0.91 GBq. Prescribed dose was entered into the Treatment Worksheet as 0.91 mCi. Dose activity delivered to the interventional radiology procedure room (Dose In-Vial) was recorded as 0.96 mCi. Analysis: Radioactivity units of measurement varied between Written Directive and Treatment Worksheet. Radioactivity activity readings from the dose calibrator were recorded with a systematic error. Calibrator reading multiplication factor(x10) was not applied. Therefore, the vial pre-dispense Y-90 activity reading of 8.62 mCi should have been recorded as 86.2 mCi. Dose activity delivered to the IR procedure room was in fact 9.60 mCi rather than 0.96 mCi. Y-90 SIR-Spheres treatment on 3/30/2018 was incomplete because the prescribed 0.91 GBq prescribed dose was not administered. Standard post-procedure verification check identified the under treatment. The patient was informed by the prescribing physician and scheduled for a second treatment on 4/6/2018. The second Y-90 SIR-Spheres treatment was performed on 4/6/2018 and the remaining dose was administered to complete administration of the prescribed 0.91 GBq. Washington State Incident Number: WA-18-010. 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 53344 +/-
Where
Virginia Mason Medical Center Seattle, Washington (NRC Region 4)
License number:	WN-M048-1
Organization:	Wa Office Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+462.83 h19.285 days <br />2.755 weeks <br />0.634 months <br />)
Opened:	Tristan Hay 13:50 Apr 18, 2018
NRC Officer:	Steven Vitto
Last Updated:	Apr 18, 2018
53344 - NRC Website
v • d • e

v t e Emergency Notification System
Virginia Mason Medical Center with Agreement State
WEEKMONTHYEAR2018-03-30T07:00:00 [Table view]
[ENS list for Virginia Mason Medical Center]

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