ENS 53859

v t e ENS Event
06:00 Feb 4, 2019
Title	Agreement State Report - Underdose Exceeding 20 Percent of the Prescribed Dose
Event Description	The following was received via email from the state of Illinois: Alexian Brothers Medical Center has advised that an attempted intravascular brachytherapy procedure utilizing a Novoste BetaCath System [containing a sealed source of Sr-90] appears to have resulted in a medical event with an underdose exceeding 20 percent of the prescribed dose. The source train was unable to reach the target location after three attempts, stopping approximately 60mm proximal. The source train was retracted without complication after a 'few seconds' during each attempt. The prescribed exposure was 18.4 Gy. The licensee estimates the unintended area receiving dose (aorta) received 0.006 Sv, less than the 0.5 Sv reporting requirement. This matter is being reported due to the fact the intended tissue received less than 20 percent of the intended dose. This event is ongoing and the report will be amended as details become available. This will be reported to NMED today. There is no adverse medical consequence expected for the patient. Item Number: IL 190006 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 53859 +/-
Where
Alexian Brothers Medical Center Elk Grove Village, Illinois (NRC Region 3)
License number:	!L-01418-01
Organization:	Illinois Emergency Mgmt. Agency
Reporting

Agreement State
Time - Person (Reporting Time:+11.53 h0.48 days <br />0.0686 weeks <br />0.0158 months <br />)
Opened:	Gary Forsee 17:32 Feb 4, 2019
NRC Officer:	Ossy Font
Last Updated:	Feb 4, 2019
53859 - NRC Website
v • d • e

v t e Emergency Notification System
Alexian Brothers Medical Center with Agreement State
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