ENS Event | |
|---|---|
06:00 Dec 15, 2017 | |
| Title | Agreement State Report - Underdose |
| Event Description | The following information was received from the State of Illinois:
The University of Chicago Medical Center reported an underdose of Y90 Theraspheres today [12/19/17] to a patient. 53.4 % of dose was delivered with 46.6% stuck in catheter. 21 mCi was ordered and 11.21 was delivered. CT scan verified dose administered in correct location. On 12/18/17, it was still undetermined why remaining dose hung up in catheter. Additional dose [is] being ordered to complete the therapy as a fractionated dose. The licensee is investigating why the catheter became blocked. A 15 day written report will follow. Illinois Incident: IL177059 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 Chicago Hospital Chicago, Illinois (NRC Region 3) | |
| License number: | IL-01678-02 |
| Organization: | Illinois Emergency Mgmt. Agency |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+107.08 h4.462 days <br />0.637 weeks <br />0.147 months <br />) | |
| Opened: | Gibb Vinson 17:05 Dec 19, 2017 |
| NRC Officer: | Vince Klco |
| Last Updated: | Dec 19, 2017 |
| 53127 - NRC Website | |
University Of Chicago Hospital with Agreement State | |
WEEKMONTHYEARENS 575472025-02-05T06:00:0005 February 2025 06:00:00
[Table view]Agreement State Lost I-125 Seed ENS 553102021-06-15T05:00:00015 June 2021 05:00:00 Agreement State Medical Event - Underdose ENS 540192019-04-19T05:00:00019 April 2019 05:00:00 Agreement State Agreement State Report - Lost and Recovered I-125 Source ENS 531272017-12-15T06:00:00015 December 2017 06:00:00 Agreement State Agreement State Report - Underdose ENS 422072005-09-12T06:00:00012 September 2005 06:00:00 Agreement State Illinois Agreement State Report - Medical Misadministration 2025-02-05T06:00:00 | |