ENS Event | |
|---|---|
05:00 Mar 13, 2026 | |
| 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 by a consultant for Methodist Medical Center of Illinois to report that a patient, treated with Y-90 Theraspheres to the right hepatic lobe last month, was scheduled for a Y-90 Theraspheres treatment to the left hepatic lobe on Friday, March 13, 2026. Angiographic images taken just prior to the Y-90 administration confirmed the proper placement of the microcatheter tip to the 2 left hepatic arterial branches; however, after the treatment, single photon emission computed tomography (SPECT)/computed tomography (CT) imaging only showed activity in the right hepatic lobe. The authorized user (AU) reported that the catheter tip must have prolapsed into the adjacent right hepatic artery during administration, causing the activity to go to the right hepatic lobe again. No untoward effects are expected to the patient since the dose was distributed within the right hepatic lobe in a similar distribution pattern (into the hepatic metastases) at the previous post treatment scan with the exposure predominantly at the site of the disease. The AU performing the treatment wants the patient to get a Cu-64 dotatate scan in 4 weeks to evaluate whether there has been a favorable response achieved in the right lobe from the Y-90 and then schedule the patient for a Y-90 treatment to the left hepatic lobe. At this time, the licensee has confirmed that the patient was notified but is still gathering information regarding notification of the referring physician. This matter is reportable under 32 Illinois Administrative Code 335.1080(a)(1)(C) no later than the next calendar day after discovery of the medical event. Reporting requirements were not met by the licensee and will be addressed through forthcoming inspection correspondence. A reactive inspection will be conducted next week to interview staff, review documents and images, and gather information as to root cause and proposed corrective actions. Illinois Item Number: IL260008 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 | |
|---|---|
| Methodist Medical Center Peoria, Illinois (NRC Region 3) | |
| License number: | IL-01204-01 |
| Organization: | Illinois Emergency Mgmt. Agency |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+105.07 h4.378 days <br />0.625 weeks <br />0.144 months <br />) | |
| Opened: | Kim Stice 14:04 Mar 17, 2026 |
| NRC Officer: | Kerby Scales |
| Last Updated: | Mar 17, 2026 |
| 58204 - NRC Website | |
Methodist Medical Center with Agreement State | |
WEEKMONTHYEARENS 582042026-03-13T05:00:00013 March 2026 05:00:00
[Table view]Agreement State Medical Event 2026-03-13T05:00:00 | |