ENS Event | |
|---|---|
05:00 Aug 13, 2021 | |
| Title | Medical Event |
| Event Description | The following information was obtained from the Illinois Emergency Management Agency (the Agency) via email:
Loyola University Medical Center contacted the Agency this afternoon to report a medical underdose of Lu-177 that occurred today, August 13, 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 approximately 1500 CDT on August 13, 2021, to report that a patient scheduled to receive 200 mCi of Lu-177, Lutathera therapy for neuroendocrine tumors, received only 14 percent of the dose prescribed (28 mCi) in the written directive. The underdosing was intentionally aborted by the authorized user after the patient advised they had received the planned chemotherapy injection the day before, rather than after the radiopharmaceutical administration per procedure. The licensee is investigating root cause. The licensee is calculating organ dose to the kidney, but preliminary estimates are 67 rad. If the dose falls beneath 50 rad, the incident may be retracted. Notification to the patient and the referring physician has been completed. Agency inspectors are awaiting additional information but plan a reactive inspection within 10 days. 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 as additional information becomes available. 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 | |
|---|---|
| Loyola University Medical Center Maywood, Illinois (NRC Region 3) | |
| License number: | IL-01131-02 |
| Organization: | Illinois Emergency Mgmt. Agency |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+11.73 h0.489 days <br />0.0698 weeks <br />0.0161 months <br />) | |
| Opened: | Gary Forsee 16:44 Aug 13, 2021 |
| NRC Officer: | Howie Crouch |
| Last Updated: | Aug 13, 2021 |
| 55406 - NRC Website | |
Loyola University Medical Center with Agreement State | |
WEEKMONTHYEARENS 554062021-08-13T05:00:00013 August 2021 05:00:00
[Table view]Agreement State Medical Event ENS 553932021-08-02T05:00:0002 August 2021 05:00:00 Agreement State Medical Underdose Exceeding 20 Percent ENS 551992021-04-19T05:00:00019 April 2021 05:00:00 Agreement State Medical Event ENS 494842013-10-29T05:00:00029 October 2013 05:00:00 Agreement State Administration of Less than the Prescribed Dose to a Patient ENS 493332013-09-07T05:00:0007 September 2013 05:00:00 Agreement State Agreement State Report - Radiopharmaceutical Package Had External Contamination 2021-08-02T05:00:00 | |