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
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. |
| 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 | |
Multi-Care Health System Auburn Event with Agreement State | |
WEEKMONTHYEARENS 568282023-10-31T16:00:00031 October 2023 16:00:00
[Table view]Agreement State Underdoseof Y-90 Microspheres 2023-10-31T16:00:00 | |