ENS 56741

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v t e ENS Event
05:00 Apr 14, 2023
Title	Agreement State - Patient Underdose
Event Description	The following information was received from the state of Illinois via email: During the course of a routine inspection at the licensee's facility on 9/14/23, inspectors discovered an underdose of a TheraSphere Y-90 treatment performed on 4/14/2023. A patient was receiving treatment for two different liver segments. The first TheraSphere dose to liver segment 3 was prescribed at 200 Gy and the patient only received 150 Gy (75 percent of the intended dose). A second written directive for segment two was successfully delivered (200 Gy prescribed and 194 Gy delivered). At the bottom of the segment 3 written directive an AMP [accredited medical practitioner] wrote 'Due to possible air in tubing, dose to segment 3 was slightly underdosed. Cumulative dose to both segments is 86 percent of [prescribed]'. Inspectors informed the licensee that each written directive is a stand alone document and that this would qualify as a medical event. On 9/15/23, the authorized user [AU] physician advised there was no adverse impact to the patient. The licensee advised the referring physician and was working to contact the patient. The AU determined the dose was medically sufficient. The licensee is aware of the 15 day reporting requirement and a written report is pending. Illinois Item Number: IL230026 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 56741 +/-
Where
Advocate Christ Hospital And Medical Center Oak Lawn, Illinois (NRC Region 3)
License number:	IL-01720-01
Organization:	Illinois Emergency Mgmt. Agency
Reporting

Agreement State
Time - Person (Reporting Time:+3705.63 h154.401 days <br />22.057 weeks <br />5.076 months <br />)
Opened:	Gary Forsee 14:38 Sep 15, 2023
NRC Officer:	Kerby Scales
Last Updated:	Sep 15, 2023
56741 - NRC Website
v • d • e

v t e Emergency Notification System
Advocate Christ Hospital And Medical Center with Agreement State
WEEKMONTHYEAR2023-04-14T05:00:00 [Table view]
[ENS list for Advocate Christ Hospital And Medical Center]

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