ENS 56828

v t e ENS Event
16:00 Oct 31, 2023
Title	Underdoseof Y-90 Microspheres
Event Description	The following information was received from the Washington State Department of Health via email: At approximately 0900 (PDT) on10/31/2023 at the Auburn Medical Center, a patient was treated with Y-90 Theraspheres utilizing three separate vials. The first vial was administered without issue, however, the second and third vials experienced some resistance as noted by the authorized physician. All three vials were administered by approximately 9:45 AM. The licensee estimated that the patient received 54.5 percent of the targeted 118 Gray total dose to the liver. The patient was not held and was in post-procedure recovery for a few hours before being discharged. Washington Incident Number: WA-23-029 * * UPDATE ON 11/15/23 AT 1855 EST FROM BORIS TSENOV TO ERIC SIMPSON * * * The following information was received from the Washington State Department of Health via email: Attached is the final report for the reported medical event # WA-23-029. We are also reviewing the event closely and are available to provide further information if needed. Notified R4DO (Vossmar) and NMSS Events via email. 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 56828 +/-
Where
Multi-Care Health System Auburn Event Auburn, Washington (NRC Region 4)
License number:	WN-M017
Organization:	Wa Office Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+43.05 h1.794 days <br />0.256 weeks <br />0.059 months <br />)
Opened:	Boris Tsenov 11:03 Nov 2, 2023
NRC Officer:	Thomas Herrity
Last Updated:	Nov 16, 2023
56828 - NRC Website
v • d • e

v t e Emergency Notification System
Multi-Care Health System Auburn Event with Agreement State
WEEKMONTHYEAR2023-10-31T16:00:00 [Table view]
[ENS list for Multi-Care Health System Auburn Event]

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