The following information was provided by the
Illinois Emergency Management Agency (The Agency) via email:
The Agency was contacted on 12/14/22 by the medical physicist for Alexian Brothers Medical Center to advise that a Y-90 microsphere administration conducted that morning resulted in a reportable under dose. The administered amount was 20.4 percent lower than that specified in the written directive. This was not a stasis case. The licensee has tried multiple times, but has so far been unable to reach the patient for notification. The referring physician has been notified. Agency inspectors have gathered preliminary information but will conduct a reactionary site visit on Tuesday, 12/20/2022. More information will be provided once it becomes available.
Illinois Event Number: IL220043
- * * UPDATE ON 01/10/2023 AT 1535 EST FROM GARY FORSEE TO ERNEST WEST * * *
When initially reported, this was not identified as a stasis case. Both the patient and the referring physician were notified within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />. Agency inspectors conducted a reactionary site visit on 12/20/2022. Upon further discussion and investigation, the authorized user (AU) and authorized medical physicist (AMP) believe the procedure may have reached stasis. The AMP acknowledged that additional training needed to be provided to the treatment team regarding procedures reaching stasis. The licensee determined the root cause to be failure to identify stasis. Agency inspectors determined the potential root cause as a failure to follow procedures and lack of sufficient training to the newly hired AU regarding stasis. This incident and the licensee's procedures will be reviewed during the next routine inspection. This matter may be considered closed.
Notified R3DO (Edwards) and NMSS Event Notifications via email.
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.