The following was received from the Radioactive Materials Inspection & Enforcement, of the
Illinois Emergency Management Agency (the Agency) via email:
Rush University Medical Center in Chicago, IL-01766-01, contacted the Agency the afternoon of June 4, 2021, to report a medical underdose of Y-90 that occurred on June 3, 2021. Although information provided was preliminary, no untoward medical impact is expected to the patient.
The Radiation Safety Officer for the licensee, contacted the Agency at 10:05 on June 4, 2021, to report a patient scheduled to receive Y-90 microsphere therapy (Theraspheres) received only 75 percent of the dose prescribed in the written directive. The Agency understands this to be one of two fractions delivered. Additional data is forthcoming.
Reportedly, the underdose was due to a pinch clamp that was remaining on the infusion line during administration. It was noticed after the authorized user felt more pressure than normal when pushing the syringe, and stopped. The clamp was removed, and the authorized user completed the administration. No personnel or area contamination occurred.
The system was flushed five times to ensure no microspheres were caught in the tubing of the kit. Images of the waste container were taken immediately after the event, showing the remaining microspheres were contained in the inlet and outlet lines. Following the manufacturer's procedures, the license determined the patient only received 21.62 mCi of the intended 28.86 mCi. The licensee believes that it was still a clinically effective dose.
Agency staff are evaluating, and this report will be updated as information becomes available.
Illinois Item Number: IL210017
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.