ENS 55369

v t e ENS Event
05:00 Apr 23, 2021
Title	Y-90 Microsphere Underdose
Event Description	The following was received from the Illinois Emergency Management Agency (the Agency) via email: The RSO [Radiation Safety Officer] called the Agency on July 21, 2021, to report that a patient scheduled to receive Y-90 microsphere therapy (SIR Spheres) for hepatocellular cancer on April 23, 2021, received only 35 percent of the dose prescribed in the written directive. The underdosing was reported as due to a clogged catheter. No personnel or area contamination was reported. The licensee reported that the dose delivered was still a `clinically effective dose' to the patient and was following up to see if any further treatment was planned. The RSO discovered the underdosing/medical event during an audit he was conducting in Radiation Therapy on July 20, 2021. Notification to the referring physician was made as required; however, confirmation that notification to the patient was made is pending. A reactionary inspection will be performed. Item Number: IL210020 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 55369 +/-
Where
University Of Illinois - Chicago Chicago, Illinois (NRC Region 3)
License number:	IL-01883-01
Organization:	Illinois Emergency Mgmt. Agency
Reporting

Agreement State
Time - Person (Reporting Time:+2148.6 h89.525 days <br />12.789 weeks <br />2.943 months <br />)
Opened:	Robin Muzzalupo 17:36 Jul 21, 2021
NRC Officer:	Ossy Font
Last Updated:	Jul 21, 2021
55369 - NRC Website
v • d • e

v t e Emergency Notification System
University Of Illinois - Chicago with Agreement State
WEEKMONTHYEAR2021-09-27T05:00:00 [Table view]
[ENS list for University Of Illinois - Chicago]

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