ENS 55214

v t e ENS Event
07:00 Apr 16, 2021
Title	Patient Underdose
Event Description	The following is a summary of an email received the State of Washington: The licensee reported a medical event involving an underdose administration of Y-90 Theraspheres on April 16, 2021. The event resulted in an underdose to the liver. Two vials of Y-90 were to be delivered to two different locations in the liver, however surveys after injection of both vials revealed not all activity in vials made it into the patient. The planned activity for each dose was 0.79 GBq. Post treatment measurement of percent dose delivered for dose `A' and dose `B' was 60 percent and 76 percent, respectively. Gamma camera imagining confirmed no Y-90 Theraspheres in the dose-vial. However, imaging visualized activity retained in the delivery tubing. Routine post-imaging demonstrated microsphere distribution in liver segments 4A and 4B. The activity delivered was 0.465 GBq and 0.594 GBq, respectively. Washington State Incident Number WA-21-008. 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 55214 +/-
Where
Virginia Mason Franciscan Health Seattle, Washington (NRC Region 4)
License number:	WN-M048-1
Organization:	Wa Office Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+248.25 h10.344 days <br />1.478 weeks <br />0.34 months <br />)
Opened:	Tristan Hay 15:15 Apr 26, 2021
NRC Officer:	Kerby Scales
Last Updated:	Apr 26, 2021
55214 - NRC Website
v • d • e

v t e Emergency Notification System
Virginia Mason Franciscan Health with Agreement State
WEEKMONTHYEAR2021-04-16T07:00:00 [Table view]
[ENS list for Virginia Mason Franciscan Health]

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