ENS Event | |
|---|---|
05:00 Jul 22, 2025 | |
| Title | Medical Event |
| Event Description | The following information was provided by the Illinois Emergency Management Agency (the Agency) via phone and email:
The Agency was contacted on July 23, 2025, by Rush University Medical Center in Chicago to advise of an administration of Y-90 Theraspheres which resulted in an underdose exceeding 20 percent. The incident occurred on July 22, 2025. No untoward medical impact to the patient is expected. The Agency was contacted by the radiation safety officer for Rush University Medical Center (radioactive materials license: IL-01766-01), on July 23, 2025, to report that a patient prescribed 47.42 mCi of Y-90 Theraspheres on July 22, 2025, received only 36.81 mCi of the prescribed dose. The patient has been notified, and inspectors will verify that the referring physician was notified during a reactive inspection scheduled to occur on July 29, 2025. There was no reported adverse impact to the patient. The licensee reported using a smaller than recommended catheter due to the area being treated. The underdose (22.4 percent deviation between the prescribed and administered dose) meets the criteria as a reportable event under 32 Illinois Administrative Code 335.1080. The prescribed and administered dose (in terms of Gy) will be confirmed on site. The investigation remains ongoing. This medical event will be reported to the NRC Operations Center today, July 24, 2025. Illinois item number: IL250029 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 | |
|---|---|
| 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:+59.02 h2.459 days <br />0.351 weeks <br />0.0808 months <br />) | |
| Opened: | Gary Forsee 16:01 Jul 24, 2025 |
| NRC Officer: | Ernest West |
| Last Updated: | Jul 24, 2025 |
| 57825 - NRC Website | |
Rush University Medical Center with Agreement State | |
WEEKMONTHYEARENS 578252025-07-22T05:00:00022 July 2025 05:00:00
[Table view]Agreement State Medical Event ENS 575212025-01-29T06:00:00029 January 2025 06:00:00 Agreement State Medical Event ENS 573852024-10-14T05:00:00014 October 2024 05:00:00 Agreement State Medical Underdose ENS 569422024-01-31T06:00:00031 January 2024 06:00:00 Agreement State Medical Underdose ENS 567662023-09-28T05:00:00028 September 2023 05:00:00 Agreement State Underdose to Patient ENS 535602018-08-23T05:00:00023 August 2018 05:00:00 Agreement State Illinois Agreement State Report - Medical Event ENS 465432010-11-23T06:00:00023 November 2010 06:00:00 Agreement State Agreement State Report Involving a Medical Event 2025-07-22T05:00:00 | |