ENS Event | |
|---|---|
06:00 Dec 30, 2021 | |
| Title | Underdose to Patient |
| Event Description | The following information was provided by the the state of Illinois via email:
During a 2/16/22 inspection, inspectors discovered an unreported medical event at The Carle Foundation (IL-01156-01) that occurred on December 30, 2021. No adverse patient impact reported. This was reported to the Headquarters Operations Officers on 2/17/2022. DETAILS: Agency inspectors performed a routine inspection on 2/16/2022, of The Carle Foundation d/b/a The Carle Foundation Hospital. During a review of Y-90 Theraspheres procedures on the afternoon of 2/16/2022, inspectors noted an unreported medical event which occurred on December 30, 2021. Inspectors noted that on 12/30/2021, a written directive to deliver 0.30 GBq Y-90 Theraspheres to the left hepatic artery was prepared; however, only 0.11 GBq (37 percent) was delivered. The licensee reported using a smaller microcatheter than usual. No further treatment to the patient is planned. The authorized user advised that the dose delivered was medically satisfactory for this case. The event remains under investigation. Item Number: IL220005 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 | |
|---|---|
| The Carle Foundation Hospital Urbana, Illinois (NRC Region 3) | |
| License number: | IL-01156-01 |
| Organization: | Illinois Emergency Mgmt. Agency |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+1185.03 h49.376 days <br />7.054 weeks <br />1.623 months <br />) | |
| Opened: | Robin Muzzalupo 15:02 Feb 17, 2022 |
| NRC Officer: | Karen Cotton-Gross |
| Last Updated: | Feb 17, 2022 |
| 55744 - NRC Website | |
The Carle Foundation Hospital with Agreement State | |
WEEKMONTHYEARENS 557442021-12-30T06:00:00030 December 2021 06:00:00
[Table view]Agreement State Underdose to Patient 2021-12-30T06:00:00 | |