ENS Event | |
|---|---|
06:00 Feb 15, 2021 | |
| Title | Patient Underdose |
| Event Description | The following information was received from Illinois Emergency Management Agency (Agency) via E-mail:
Agency inspectors performed a routine inspection on 1/6/2022. During a review of Y-90 TheraSphere procedures, inspectors noted an unreported medical event which occurred on 2/15/2021. On 2/15/2021, a written directive to deliver 1.93 GBq Y-90 TheraSpheres to the right hepatic artery was prepared. The procedure performed that same day was halted prematurely due to an unwinding of the male luer lock connector and only 0.49 GBq were administered. To compensate for the underdose, the licensee created an additional written directive and administered 1.17 GBq Y-90 TheraSpheres without incident [on the same day as the initial procedure]. The licensee was under the impression that this was not a reportable medical event since they were able to compensate the dose with an additional vial they had on hand and were ultimately able to deliver the intended dose. Item Number: IL220001 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 | |
|---|---|
| Northwestern Memorial Hospital Chicago, Illinois (NRC Region 3) | |
| License number: | IL-01037-02 |
| Organization: | Illinois Emergency Mgmt. Agency |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+7979.25 h332.469 days <br />47.496 weeks <br />10.93 months <br />) | |
| Opened: | Robin G. Muzzalupo 17:15 Jan 13, 2022 |
| NRC Officer: | Lloyd Desotell |
| Last Updated: | Jan 13, 2022 |
| 55704 - NRC Website
Loading map... | |
Northwestern Memorial Hospital with Agreement State | |
WEEKMONTHYEARENS 577072025-05-12T05:00:00012 May 2025 05:00:00
[Table view]Agreement State Agreement STATE- Medical Event ENS 576712025-04-15T05:00:00015 April 2025 05:00:00 Agreement State Medical Event ENS 570972024-04-30T05:00:00030 April 2024 05:00:00 Agreement State Medical Event ENS 558422022-04-11T05:00:00011 April 2022 05:00:00 Agreement State Patient Received Dose Less than Prescribed ENS 557162022-01-27T06:00:00027 January 2022 06:00:00 Agreement State Patient Underdose ENS 557042021-02-15T06:00:00015 February 2021 06:00:00 Agreement State Patient Underdose ENS 467922011-04-27T05:00:00027 April 2011 05:00:00 Agreement State Agreement State Report - Underdose Due to Clumping in the Delivery Device ENS 448162009-01-29T06:00:00029 January 2009 06:00:00 Agreement State Agreement State Report - Personnel Contamination from I-131 Spill in Hot Lab ENS 423542006-02-21T06:00:00021 February 2006 06:00:00 Agreement State Agreement State - Loss of Iridium Seed Strand Following Medical Treatment 2025-05-12T05:00:00 | |