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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 53344 | 30 March 2018 07:00:00 | Agreement State | Misadministration of Sir-Spheres Y-90 Microspheres Resulting in an Underdose | The following was received from the State of Washington via email: Patient was under treated with Y-90 SIR-Spheres Microspheres. Prescribed dose was 24.59 mCi. Patient was treated with 8.9 mCi. Background: SIR-Spheres Microspheres Activity Calculator determined a treatment dose of 0.91 GBq (24.59 mCi). Written Directive was signed for 0.91 GBq. Prescribed dose was entered into the Treatment Worksheet as 0.91 mCi. Dose activity delivered to the interventional radiology procedure room (Dose In-Vial) was recorded as 0.96 mCi. Analysis: Radioactivity units of measurement varied between Written Directive and Treatment Worksheet. Radioactivity activity readings from the dose calibrator were recorded with a systematic error. Calibrator reading multiplication factor(x10) was not applied. Therefore, the vial pre-dispense Y-90 activity reading of 8.62 mCi should have been recorded as 86.2 mCi. Dose activity delivered to the IR procedure room was in fact 9.60 mCi rather than 0.96 mCi. Y-90 SIR-Spheres treatment on 3/30/2018 was incomplete because the prescribed 0.91 GBq prescribed dose was not administered. Standard post-procedure verification check identified the under treatment. The patient was informed by the prescribing physician and scheduled for a second treatment on 4/6/2018. The second Y-90 SIR-Spheres treatment was performed on 4/6/2018 and the remaining dose was administered to complete administration of the prescribed 0.91 GBq. Washington State Incident Number: WA-18-010. 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 52131 | 27 July 2016 07:00:00 | Agreement State | Agreement State Report - Patient Received Less than the Prescribed Dose of I-131 | The following information was provided by the State of Washington via email: At approximately 3:50 pm (PDT) on Thursday, July 28th 2016, the Director of Radiology of Virginia Mason Medical Center called the radioactive materials section (WA Office of Radiation Protection) to report a medical event. The event occurred on the previous day, July 27th 2016, but was not noticed until the 28th . A patient was supposed to receive 120.8 mCi of I-131 in the form of two capsules for thyroid treatment. However, the patient only received one capsule resulting in the patient only receiving 53 mCi of the 120.8 mCi. The event was discovered (8:45 am (on) July 28, 2016) when an I-131 capsule was returned to the pharmacy on the 28th and it was noticed that the patient did not get both capsules as intended. 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 43778 | 9 November 2007 08:00:00 | Agreement State | Agreement State Report - High External Radiation Levels on I-125 Medical Seed Shipment | The State provided the following information via email: Bard Brachytherapy, a vendor of I-125 prostate seeds based in Carol Stream Illinois, notified the Illinois Radiation Control Program that they had received a shipment of seeds from a state of Washington licensee, Virginia Mason Medical Center, which had excessive external radiation levels. The Illinois, Division of Nuclear Safety promptly notified the state of Washington, Department of Health via phone and email. At the surface the package was reported to be reading 600 mR/hr while readings at a meter were 1.4 mR/hr. It was determined the lid of the pig which contained the returned seeds (51 seeds total from an original shipment of 90, with an activity of 1406 MBq (38 mCi)) had shifted during transport allowing a beam of radiation to penetrate the external surface of the transport package. Immediately upon notification from Illinois, the shipper (Virginia Mason Medical Center) was contacted. Washington DOH staff spoke with the Authorized Medical Physicist who provided this information: This was the remainder of a shipment originally received by the licensee on 5 November 2007. It arrived with a total of 90, I-125 seeds with an average activity of 0.4 mCi/seed. Thirty-nine of the original 90 seeds were implanted and the remaining 51 were repackaged according to the manufacturer's (Bard's) instructions. At the time of shipment, licensee records show a dose rate at the surface of the package of 0.14 mR/hr, and a reading at one meter of 15 microR/hr. The licensee, upon questioning, acknowledged this shipment differed from all prior shipments from this vendor because it was a sterile shipment (all prior shipments had been non-sterile) and thus came in new/different packaging with different packaging instructions. The licensee firmly believes the lid of the pig was dislodged due to abuse during shipment. The licensee stated they had been in contact with Bard concerning this incident. Bard has agreed that on all future such shipments for clients in the state of Washington (it was unclear if corrective action would be extended to clients in other states as well) Bard will include more tape, for sealing the 'lid' of the pig, and that repackaging shipping instructions would also include steps for taping the pig closed prior to shipment. See also EN #43775, Illinois Agreement State report. | ||
| ENS 43035 | 29 November 2006 08:00:00 | Agreement State | Agreement State Report - Lost Cancer Therapy Seeds | The State provided the following information via email: Date and time of Event: 29 November 2006 (reported to DOH on 5 December 2006) Location of Event: Seattle, Washington (main campus operating room) ABSTRACT: A Central Services employee, who was to only clean bodily fluids from the exterior of a cancer therapy seed applicator post-use, apparently also opened the spring-loaded device displacing the remaining seeds. The remaining seven seeds in the applicator (one was later found in garbage, six are still missing) popped out. The six seeds were apparently flushed down the drain by mistake. Surveys cannot locate the seeds at this time. Cause, contributing factors, and corrective actions have not been determined as of this writing. At this time no consequences are expected and there has been no media attention. Isotope and Activity involved: Iodine-125, sealed brachytherapy seeds. Six seeds, total of 97.7 MegaBq (2.64 millicuries). Overexposures? (number of workers/members of the public; dose estimate; body part receiving dose; consequence): None noted or expected. Lost, Stolen or Damaged? (mfg., model, serial number): Lost, mfg/model not yet known. Disposition/recovery: To be determined. Leak test? Original, by Manufacturer, within past six months. Release of activity? The seeds were apparently released to the waste water drain. No contamination was found. Consequences: None so far, none expected. WA-06-068
The State provided the following information via email: The actual cause was determined to be inadequate training of the CS employee. The licensee has revised the procedure for handling seed implants. Now only a properly trained scrub nurse or tech will handle the applicator and accessories. At this time no consequences are expected and there has been no media attention." The six missing sources were never recovered. Notified R4DO (M. Hay) and NMSSEO (G. Morell) THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. |