ENS Event | |
|---|---|
06:00 Dec 28, 2016 | |
| Title | Underdose to Patient |
| Event Description | The following information was provided by the Illinois Emergency Management Agency (Agency) via email:
At 1400 CST on February 21, 2022, The Carle Foundation notified the Agency to advise of an unreported medical event that occurred on December 28, 2016. No adverse patient impact reported. This will be reported to the NRC this morning. Following a comprehensive review of Y-90 Therasphere procedures performed over the last several years, The Carle Foundation d/b/a The Carle Foundation Hospital identified an additional medical event in addition to the one identified during a recent Agency inspection on 2/16/22, that was not reported as required. On 12/28/2016, a written directive to deliver 0.51 GBq Y-90 Theraspheres to the Superior Branch of Segment 3 (liver) was prepared; however, only 0.16 GBq (31.4%) was delivered. The licensee was under the impression that this was not a reportable medical event since they revised the treatment plan and written directive after the procedure. Although still under investigation, the root cause appears to be the use of a smaller microcatheter than recommended. No further treatment to the patient is planned. The authorized user advised that the dose delivered to the critical mass of the segment treated was medically satisfactory for this case. Illinois Report # IL220006 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 Urbana, Illinois (NRC Region 3) | |
| License number: | IL-01156-01 |
| Organization: | Illinois Emergency Mgmt. Agency |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+45175 h1,882.292 days <br />268.899 weeks <br />61.881 months <br />) | |
| Opened: | Zach Mengel 13:00 Feb 22, 2022 |
| NRC Officer: | Karen Cotton-Gross |
| Last Updated: | Feb 22, 2022 |
| 55751 - NRC Website | |
The Carle Foundation with Agreement State | |
WEEKMONTHYEARENS 557512016-12-28T06:00:00028 December 2016 06:00:00
[Table view]Agreement State Underdose to Patient 2016-12-28T06:00:00 | |