ENS Event | |
|---|---|
05:00 Apr 11, 2022 | |
| Title | Patient Received Dose Less than Prescribed |
| Event Description | The following information was provided by the Illinois Emergency Management Agency (the Agency) via email:
The Radiation Safety Officer for Northwestern Memorial HealthCare, contacted the Agency on 4/12/2022 to advise of a Y-90 microsphere administration in which the patient received only 70 percent of the prescribed dose. Of note, the [authorized user] noticed sluggish flow during the first flush of saline through the device, possibly due to a kink in the micro catheter as it exits the base catheter. No contamination or other issues were identified. No adverse patient impacts are expected. The [authorized user] was satisfied that the dose was adequate as delivered and will assess with MRI in 1 month as per protocol. The Agency will dispatch inspectors to review procedures and determine a root cause. Item Number: IL220012 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:+56.17 h2.34 days <br />0.334 weeks <br />0.0769 months <br />) | |
| Opened: | Robin Muzzalupo 13:10 Apr 13, 2022 |
| NRC Officer: | Mike Stafford |
| Last Updated: | Apr 13, 2022 |
| 55842 - NRC Website
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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 | |