ENS 55744

v t e 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.

ENS 55744 +/-
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
v • d • e

v t e Emergency Notification System
The Carle Foundation Hospital with Agreement State
WEEKMONTHYEAR2021-12-30T06:00:00 [Table view]
[ENS list for The Carle Foundation Hospital]

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