ENS Event | |
|---|---|
05:00 Jun 15, 2021 | |
| Title | Medical Event - Underdose |
| Event Description | The following was received from the Illinois Emergency Management Agency (the Agency) via email:
University of Chicago Medical Center contacted the Agency on the afternoon of 6/15/21 to report a medical underdose of Lu-177 that occurred that day. Although information provided was preliminary, no untoward medical impact is expected to the patient. The Radiation Safety Officer (RSO) for the licensee contacted the Agency at approximately 1615 CDT on June 15, 2021, to report that a patient scheduled to receive 200 mCi of Lu-177, Lutathera therapy for neuroendocrine tumors, received only 68 percent of the dose prescribed (136 mCi) in the written directive. The underdosing was reportedly due to leakage in the adaptor/needle connection. No personnel or area contamination occurred. The licensee is still evaluating whether or not the remaining dose will be delivered at a future date. The RSO confirmed the patient and referring physician were notified within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />. IEMA inspectors will perform a reactive inspection on June 17, 2021. 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. This report will be updated once additional details become available on 6/17/21. Item Number: IL210019 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:+32.17 h1.34 days <br />0.191 weeks <br />0.0441 months <br />) | |
| Opened: | Gary Forsee 13:10 Jun 16, 2021 |
| NRC Officer: | Jeffrey Whited |
| Last Updated: | Jun 16, 2021 |
| 55310 - 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 | |