ENS 56317

v t e ENS Event
08:00 Jan 18, 2023
Title	Patient Underdose
Event Description	The following is a summary of information provided by the Washington State Department of Health (DOH), Radioactive Materials Section via email: The licensee reported that a Y-90 TheraSphere liver treatment was completed in accordance with manufacturer requirements and nothing out of the ordinary was observed. However, during a subsequent step to flush the system with saline, the technician, who is not an authorized user or radioactive material user, noticed bubbles coming up above the vial. Wipe samples of the procedure equipment were counted and showed radioactivity. A second flush of the system was initiated but the same bubbles were observed and therefore the flush was stopped, and the catheter was retracted from the patient. Additional flushes were not attempted. An evaluation showed that the patient received only 33 percent of the intended dose. The activity contained in the wipes and cleaning materials accounted for the balance of the intended dose (66 percent) and was disposed of as waste. DOH has requested additional information regarding potential occupational exposures. The licensee will submit a detailed report. Washington Incident Number: WA-23-003. 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 56317 +/-
Where
Multicare Health System Tacoma, Washington (NRC Region 4)
License number:	WN-M017-1
Organization:	Wa Office Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+34.55 h1.44 days <br />0.206 weeks <br />0.0473 months <br />)
Opened:	Boris G. Tsenov 18:33 Jan 19, 2023
NRC Officer:	Lloyd Desotell
Last Updated:	Jan 19, 2023
56317 - NRC Website
v • d • e

v t e Emergency Notification System
Multicare Health System with Agreement State
WEEKMONTHYEAR2023-01-18T08:00:00 [Table view]
[ENS list for Multicare Health System]

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