ENS 52887

v t e ENS Event
05:00 Aug 4, 2017
Title	Agreement State Report - Underdose to Patient
Event Description	The following information was received via E-mail: The licensee's RSO reported an event that resulted in an underdose to the patient. At 1215 CDT on August 4, 2017, licensee staff were administering a 40.4 mCi dose of Y-90 microspheres to the patient. The preliminary finding is that the patient took a deep inspiration which moved the base catheter and possibly changed its position or created a kink in the catheter. The first 3-4 aliquots were delivered before the plunger met resistance and the procedure aborted. The licensee estimates that 21.5 mCi was delivered (underdose 46.9%). They estimate that the patient received 50+ Gy to the intended area and there were no microspheres to an unintended target. Written report forthcoming. Illinois Item Number: IL177016 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 52887 +/-
Where
Midwest Regional Medical Center Zion, Illinois (NRC Region 3)
License number:	IL-01104-01
Organization:	Illinois Emergency Mgmt. Agency
Reporting

Agreement State
Time - Person (Reporting Time:+12.4 h0.517 days <br />0.0738 weeks <br />0.017 months <br />)
Opened:	Gary Forsee 17:24 Aug 4, 2017
NRC Officer:	Donald Norwood
Last Updated:	Aug 4, 2017
52887 - NRC Website
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v t e Emergency Notification System
Midwest Regional Medical Center with Agreement State
WEEKMONTHYEAR2019-02-01T18:00:00 [Table view]
[ENS list for Midwest Regional Medical Center]

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