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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 55392 | 2 August 2021 05:00:00 | Agreement State | Medical Underdose Exceeding 20 Percent | The following information was obtained from the Illinois Emergency Management Agency (the Agency) via email: Children's Hospital of Chicago Medical Center (IL-01165-01), contacted the Agency on 8/2/21 to advise that a pediatric administration of Y-90 resulted in an underdose exceeding 20%. The incident occurred today, August 2, 2021. No untoward medical impact was expected to the patient. The licensee's radiation safety officer designee contacted (the Agency) to advise that a pediatric patient scheduled to receive Y-90 microsphere therapy (Theraspheres) for hepatocellular cancer on August 2, 2021 received only 75 percent of the dose prescribed in the written directive. A Therasphere representative was on site for the administration and did not note stasis. The licensee suspects a kink in the delivery catheter but is currently imaging the RAM waste and tubing to confirm. No personnel or area contamination was reported. It remains to be determined if the dose delivered was clinically effective or if an additional treatment is planned. The patient's father was advised. It is unclear at this point if the referring physician has been notified. Agency inspectors will perform a reactionary inspection tomorrow, August 3, 2021, to assist in determining root cause and gather the additional information required. This matter is reportable under 32 Ill. Adm. Code 335.1080(a)(1)(B). A written report will be required of the licensee within 15 days. Illinois NMED report number: IL210022 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. |