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. |
| 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 | |
Virginia Mason Franciscan Health with Agreement State | |
WEEKMONTHYEARENS 552142021-04-16T07:00:00016 April 2021 07:00:00
[Table view]Agreement State Patient Underdose 2021-04-16T07:00:00 | |