ENS Event | |
|---|---|
05:00 Apr 30, 2024 | |
| Title | Medical Event |
| Event Description | The following was provided by the Illinois Emergency Management Agency (the Agency) via email:
On April 30, 2024, the Agency was notified by Northwestern Memorial HealthCares radiation safety officer of an yttrium-90 (Y-90) TheraSphere underdose. There were no adverse patient impacts reported, and the treatment is scheduled to be repeated the following week. The initial information indicated an underdose of Y-90 TheraSpheres of near 100 percent. Additional information is forthcoming, and Agency staff will be on-site to perform a reactive inspection on May 5, 2024. Updates will be made when available.
The following information was provided by the Illinois Emergency Management Agency (the Agency) via email: Based on the May 2, 2024, reactive investigation, agency inspectors determined that this case qualifies as a medical event under 335.1080(a)(1). The authorized user (AU) stated that no negative health effects were expected for the patient and that the patient will be retreated in the future. The patient and referring physician were notified of the event within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> as required. Agency inspectors determined the potential root cause as the clumping of microspheres due to the overtightening of the tuohy luer lock. This matter may be considered closed pending further information. Notified R3DO (Szwarc) and NMSS Events Notifications (Email). IL Event Number: IL240009 A Medical Event may indicate potential problems in a medical facilitys 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:+31.5 h1.313 days <br />0.187 weeks <br />0.0431 months <br />) | |
| Opened: | Whitney Cox 12:30 May 1, 2024 |
| NRC Officer: | Eric Simpson |
| Last Updated: | May 30, 2024 |
| 57097 - 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 | |