ENS 49484
ENS Event | |
|---|---|
05:00 Oct 29, 2013 | |
| Title | Administration of Less than the Prescribed Dose to a Patient |
| Event Description | The following report was received from the Illinois Emergency Management Agency via e-mail:
On October 29, 2013, the RSO at Loyola University Medical Center (IL-01131-02) called to report a medical event which occurred at their facility the previous day. A treatment dose of 115 Gray (10.5 mCi) of Nordion's Y-90 Theraspheres was prescribed. However, at the completion of the treatment and in accordance with manufacturer's use instructions, the system was evaluated for residual material. Elevated levels were detected within the combination of the catheter, tubing and source delivery vial apparatus. Those elevated levels were determined to correspond to over 2 mCi of Y-90. A detailed evaluation revealed 8.04 mCi had been administered for a total delivered dose of 88 Gray or 76.5% of the intended dose. Most of the remaining 2.5 mCi of Y-90 was adhered within the catheter about 1 inch from the catheter/tubing interface connector despite successfully completing the treatment in less than a minute including 3 successful flushes of the system with 30 cc of sterile solution. No material was detected as remaining in the source vial which was monitored closely during the treatment with a dedicated dosimeter nor were there any observable defects in the catheter or manufacturer supplied tubing where the microspheres had accumulated. As per regulations, the patient was advised of the situation by the interventional radiologist. Neither the physician authorized user, an oncologist, nor the interventional radiologist believes that there will be any adverse impact to the patient as a result of the lowered dosage. There are no plans to supplement/repeat this treatment to deliver any remaining/additional amount of radiation nor does the licensee have any immediate corrective actions to implement in that the procedure already follows the manufacturer's recommendations. The licensee is aware of the requirement to submit a written report within 15 days. The cause of this event was equipment failure. Illinois Item Number: IL13032 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 | |
|---|---|
| Loyola University Medical Center Maywood, Illinois (NRC Region 3) | |
| License number: | IL-01131-02 |
| Organization: | Illinois Emergency Mgmt. Agency |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+33.6 h1.4 days <br />0.2 weeks <br />0.046 months <br />) | |
| Opened: | Darren Perrero 14:36 Oct 30, 2013 |
| NRC Officer: | John Shoemaker |
| Last Updated: | Oct 30, 2013 |
| 49484 - NRC Website | |
Loyola University Medical Center with Agreement State | |
WEEKMONTHYEARENS 554062021-08-13T05:00:00013 August 2021 05:00:00
[Table view]Agreement State Medical Event ENS 553932021-08-02T05:00:0002 August 2021 05:00:00 Agreement State Medical Underdose Exceeding 20 Percent ENS 551992021-04-19T05:00:00019 April 2021 05:00:00 Agreement State Medical Event ENS 494842013-10-29T05:00:00029 October 2013 05:00:00 Agreement State Administration of Less than the Prescribed Dose to a Patient ENS 493332013-09-07T05:00:0007 September 2013 05:00:00 Agreement State Agreement State Report - Radiopharmaceutical Package Had External Contamination 2021-08-02T05:00:00 | |