ENS 54804
ENS Event | |
|---|---|
05:00 Jul 28, 2020 | |
| Title | Agreement State Report- Patient Underdose |
| Event Description | The following was received from the Illinois Emergency Management Agency (IEMA) via email:
KishHealth System in Dekalb, IL (d/b/a Kishwaukee Community Hospital) contacted the IEMA at approximately 1100 CDT on 7/29/20 to report a patient scheduled to receive Y-90 microsphere therapy for hepatocellular cancer received only 58% of the dose prescribed in the written directive. While investigation is ongoing, the reportable underdose is based on licensee's pre and post-administration measurements of the dose vial and waste container, respectively. IEMA staff have contacted the licensee and are seeking additional information on post-administration imaging, status of patient/referring AU notification, the nature of the written directive (i.e., was this a fractionated dose), and the members of the treatment team. These factors, among others, will determine regulatory compliance as well as patient impact. Therefore, this report will be updated as information becomes available. IEMA is dispatching staff today (7/29/20) for a reactionary inspection. The reporting requirements for the licensee, as specified in 32 Ill. Adm. Code 335.1080(c) were met, and the licensee is aware of the need for a written report within 15 days. Illinois item number: IL200013 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 | |
|---|---|
| Illinois Emergency Mgmt. Agency Dekalb, Illinois (NRC Region 3) | |
| License number: | IL-02097-01 |
| Organization: | Illinois Emergency Mgmt. Agency |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+32.72 h1.363 days <br />0.195 weeks <br />0.0448 months <br />) | |
| Opened: | Gary Forsee 13:43 Jul 29, 2020 |
| NRC Officer: | Thomas Herrity |
| Last Updated: | Jul 29, 2020 |
| 54804 - NRC Website | |
Illinois Emergency Management Agency with Agreement State | |||
WEEKMONTHYEARENS 565742023-03-02T05:00:0002 March 2023 05:00:00 Agreement State Lost/Abandoned Source ENS 552512021-05-11T05:00:00011 May 2021 05:00:00 Agreement State Equipment Failed in Shielded Position ENS 549062020-09-22T05:00:00022 September 2020 05:00:00 Agreement State | Agreement State Report - Medical Event ENS 549052020-09-14T05:00:00014 September 2020 05:00:00 Agreement State | Agreement State Report - Loss of Yellow Ii Package Containing Approximately 61 Mci of Liquid Tl-201 ENS 548042020-07-28T05:00:00028 July 2020 05:00:00 Agreement State Agreement State Report- Patient Underdose ENS 547842020-07-14T20:30:00014 July 2020 20:30:00 Agreement State Agreement State Report - Gauge Crushed with Source Rod Extended ENS 547372020-06-04T06:00:0004 June 2020 06:00:00 Agreement State Agreement State Report - Low Level Radioactive Waste Railcar Fire ENS 547322020-05-30T12:00:00030 May 2020 12:00:00 Agreement State Agreement State Report - Damaged Gauge ENS 547022020-05-11T05:00:00011 May 2020 05:00:00 Agreement State Agreement State Report - Troxler Gauge Destroyed by Bulldozer ENS 545432020-02-21T06:00:00021 February 2020 06:00:00 Agreement State Agreement State Report - Stolen Fluorescence Analyzer Equipment ENS 545122020-02-05T06:00:0005 February 2020 06:00:00 Agreement State Agreement State Report - Lost Gauging Source ENS 545162019-02-22T06:00:00022 February 2019 06:00:00 Agreement State Agreement State Report - Reportable Equipment Failure ENS 403522003-11-24T20:15:00024 November 2003 20:15:00 Agreement State Agreement State Report - Dose to Patient Outside Intended Treatment Site 2023-03-02T05:00:00 [Table view] | |