ENS 57385

v t e ENS Event
05:00 Oct 14, 2024
Title	Medical Underdose
Event Description	The following information was provided by the Illinois Emergency Management Agency (The Agency) via phone and email: The Agency was contacted by the radiation safety officer (RSO) for Rush University Medical Center, on October 15, 2024, to report that a patient prescribed 66.67 mCi (479 Gy) of Y-90 Theraspheres on October 14, 2024, received only 20.14 mCi (144.7 Gy) of the prescribed dose. The patient has been notified and the RSO is still attempting to notify the referring physician who left on vacation immediately after the procedure. There was no reported adverse impact on the patient and the licensee is still discussing possible retreatment. The administering physician reported significant resistance during the administration and filling of the overflow vial. An investigation remains ongoing. The underdose (69.8 percent deviation between the prescribed and administered dose) meets the criteria as a reportable incident under 32 Illinois administrative code 335.1080. Inspectors will perform a reactive inspection on October 17, 2024. 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 57385 +/-
Where
Rush University Medical Center Chicago, Illinois (NRC Region 3)
License number:	IL-01766-01
Organization:	Illinois Emergency Mgmt. Agency
Reporting

Agreement State
Time - Person (Reporting Time:+56.1 h2.338 days <br />0.334 weeks <br />0.0768 months <br />)
Opened:	Whitney Cox 13:06 Oct 16, 2024
NRC Officer:	Karen Cotton-Gross
Last Updated:	Oct 16, 2024
57385 - NRC Website
v • d • e

v t e Emergency Notification System
Rush University Medical Center with Agreement State
WEEKMONTHYEAR2024-10-14T05:00:00 [Table view]
[ENS list for Rush University Medical Center]

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