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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 56911 | 29 December 2023 06:00:00 | Agreement State | Underdose | The following information was provided by the Illinois Emergency Management Agency and Office of Homeland Security (IEMA-OHS) via email: A medical administration of Y-90 microspheres that took place on 12/29/23. Advocate General Hospital in Park Ridge, IL, failed to deliver nearly 100 percent of the intended dose. There was no patient impact and the treatment will be rescheduled. The radiation safety officer (RSO) for Advocate General Hospital, contacted the IEMA-OHS Operations Center on 12/29/23, to report the above described medical underdose. The patient had been prescribed two administrations of Theraspheres Y-90 microspheres. The first administration went without issue. The second administration (from a separate written directive) called for 3.5 GBq to segment 8 of the liver. Post-administration surveys indicated that nearly 100 percent of the microspheres were still contained within the delivery tubing. The patient and referring physician were immediately notified. The RSO and the authorized user (AU) believed that the time between dose preparation and delivery may have been a contributing issue, but the investigation is ongoing. This matter is reportable by the next calendar day. The licensee met reporting requirements. Inspectors will not be dispatched until next week as there is no immediate radiation safety concern. This report will be updated as additional information becomes available. Illinois Event Number: IL230037 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. |