ENS Event | |
|---|---|
08:00 Nov 15, 2021 | |
| Title | |
| Event Description | The following is a synopsis of a report received from the State of Washington, Office of Radiation Protection via email.
On Monday, November 15, 2021 a patient undergoing cancer treatment at University of Washington Medical Center received an under dose of Y-90 TheraSpheres. The details of the intended dose to the liver (target organ) are yet to be provided. They will be forwarded when obtained.
The following information was received from the state of Washington State Department of Health via email: The University of Washington Medical Center reported that a patient received less dose than prescribed during a yttrium-90 microsphere (Nordion/BWXT model TheraSphere) liver cancer treatment on 11/15/2021. In this event, the patient was administered two dosages of yttrium-90 microspheres to treat the patient's liver at two different liver treatment sites. One dosage was 51.5 millicuries, which was successfully delivered. The other dosage was 34.1 millicuries, but only 24.2 millicuries (about 69 percent) was successfully administered. The prescribed dose was 13,100 rem, but the dose actually administered was only 9,300 rem (about 29 percent less). It appears that the microspheres that were not successfully administered remained mainly in the catheter since the radiation reading of the catheter and syringe after administration of the yttrium-90 microspheres was about 1 mR/hour instead of the usual reading of 0 mR/hour after administration. This appears to be an event where the catheter was blocked or clogged because of clumping of microspheres in the catheter. Events like these are discussed in 'NRC Information Notice 2019-12: Recent Reported Medical Events involving the Administration of Yttrium-90 Microspheres for Therapeutic Medical Procedures.' A copy of this information notice was sent to University of Washington officials in hopes that it would help them to fully understand this incident and to help them prevent future incidents from happening. WA report no.: WA-21-024 Notified R4DO (Deese) and NMSS 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 | |
|---|---|
| University Of Washington Medical Center Seattle, Washington (NRC Region 4) | |
| License number: | WN-C001-1 |
| Organization: | Washington St. Dept. Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+57.43 h2.393 days <br />0.342 weeks <br />0.0787 months <br />) | |
| Opened: | James Killingbeck 17:26 Nov 17, 2021 |
| NRC Officer: | Thomas Herrity |
| Last Updated: | Sep 19, 2022 |
| 55589 - NRC Website | |
University Of Washington Medical Center with Agreement State | |
WEEKMONTHYEARENS 555892021-11-15T08:00:00015 November 2021 08:00:00
[Table view]Agreement State Underdose 2021-11-15T08:00:00 | |