ENS 53545

v t e ENS Event
07:00 Aug 9, 2018
Title	Misadministration of Y-90 Microspheres
Event Description	This event occurred on August 9, 2018, at the VA Portland Health Care System, Portland, Oregon. The patient was to receive a prescribed dose of 134 gray to a segment of the liver as a treatment for liver cancer, with Y-90 microspheres. After the procedure, the [actual] dose to the intended segment was estimated as approximately 103 gray, 77 percent of the prescribed dose. The patient has been notified. No harm to the patient is anticipated. 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 53545 +/-
Where
Us Department Of Veterans Affairs Portland, Oregon (NRC Region 4)
Organization:	Us Department Of Veterans Affairs
Reporting

10 CFR 35.3045(a)(1)
Time - Person (Reporting Time:+36.6 h1.525 days <br />0.218 weeks <br />0.0501 months <br />)
Opened:	Edwin Leidholdt Jr. 19:36 Aug 10, 2018
NRC Officer:	Donald Norwood
Last Updated:	Aug 10, 2018
53545 - NRC Website
v • d • e

v t e Emergency Notification System
Us Department Of Veterans Affairs with 10 CFR 35.3045(a)(1)
WEEKMONTHYEAR2018-08-09T07:00:00 [Table view]
[ENS list for Us Department Of Veterans Affairs]

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