ENS Event | |
|---|---|
05:00 Apr 27, 2011 | |
| Title | Agreement State Report - Underdose Due to Clumping in the Delivery Device |
| Event Description | The following information was obtained from the State of Illinois via email:
The Radiation Safety Officer at Northwestern Memorial Hospital contacted the Illinois Emergency Management Agency on April 26th and reported that a medical event involving radiolabled Theraspheres had occurred. The treating physician attempted to perform radioembolization by placing the Y-90 microspheres in the treatment site using the appropriate Nordion Microsphere Delivery Device. However, increased resistance was felt in the administration syringe and a clump of microspheres developed between the needle injector assembly and the microcatheter connection during the initial bolus flush. Administration was halted as soon as the microsphere flow was slowed and a clump was visualized. Following a second attempt to complete the flush, the microspheres began layering within the outlet tubing. Further flushing of the system with saline did not alter the position of the remaining microspheres. The procedure was halted. Analysis of the system showed that a significant amount of the original dose had not been delivered as intended to the right hepatic lobe of the liver. Approximately 80 percent of the dose was not administered as a result of the failure. The primary cause of this incident is due to the clumping of the microspheres. However, the reason for the clumping is unknown. The intended dose of Y-90 was 59.4 mCi (2198.8 Mbq) for an exposure of 9750 rad (97.5 Gy). The administered dose was 22.7 mCi (839.9 Mbq) for an exposure of 3760 rad (37.6 Gy). Illinois Report Number: IL11049 |
| Where | |
|---|---|
| Northwestern Memorial Hospital Chicago, Illinois (NRC Region 3) | |
| License number: | IL-01037-02 |
| Organization: | Illinois Emergency Mgmt. Agency |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+12.5 h0.521 days <br />0.0744 weeks <br />0.0171 months <br />) | |
| Opened: | Daren Perrero 17:30 Apr 27, 2011 |
| NRC Officer: | Howie Crouch |
| Last Updated: | Apr 27, 2011 |
| 46792 - NRC Website
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Northwestern Memorial Hospital with Agreement State | |
WEEKMONTHYEARENS 577072025-05-12T05:00:00012 May 2025 05:00:00
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