ENS 55781

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v t e ENS Event
06:00 Mar 9, 2022
Title	Underdose to Patient
Event Description	The following information was provided by the Illinois Emergency Management Agency (the Agency) via email: The radiation safety officer (RSO) for Elmhurst Hospital contacted the Agency on 3/10/22 to advise of a Y-90 microsphere administration in which the patient received only 54 percent of the prescribed dose. The administration occurred on the morning of 3/9/22. The physician felt the delivered dose was clinically effective and no further treatment is planned. No adverse patient impacts are expected. The referring physician and patient were notified as required. Agency staff have requested copies of the written directive and associated documentation as details regarding the prescribed activity were not immediately available. Of note, the RSO advised that the authorized user felt resistance during administration and discontinued the procedure. Microspheres were reportedly observed `clumped' within the first two inches of the delivery catheter. A second, smaller vial was obtained and the written directive modified. No contamination or other issues were identified. The Agency will dispatch inspectors, likely at the beginning of next week, to review the procedure and determine root cause. Compliance with Agency regulations regarding modification to a written directive will be reviewed. This matter will be reported under NMED number IL220008. 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 55781 +/-
Where
Elmhurst Hospital Elmhurst, Illinois (NRC Region 3)
License number:	IL-01612-01
Organization:	Illinois Emergency Mgmt. Agency
Reporting

Agreement State
Time - Person (Reporting Time:+35.17 h1.465 days <br />0.209 weeks <br />0.0482 months <br />)
Opened:	Gary Forsee 17:10 Mar 10, 2022
NRC Officer:	Dan Livermore
Last Updated:	Mar 10, 2022
55781 - NRC Website
v • d • e

v t e Emergency Notification System
Elmhurst Hospital with Agreement State
WEEKMONTHYEAR2025-10-15T05:00:00 [Table view]
[ENS list for Elmhurst Hospital]

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