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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 53175 | 9 January 2018 06:00:00 | Agreement State | Illinois Agreement State Report - Medical Event | The following information was received from the State of Illinois via email: The agency (Illinois Emergency Management Agency, Bureau of Radiation Safety) was notified on 1/16/18 of a medical event that occurred on 1/9/18. Agency personnel were able to contact the licensee and obtain details on 1/17/18. The licensee's RSO advised that he was out of state for a training class and was not informed by his staff until he returned. Licensee administered Y-90 Theraspheres to a patient in 2 doses, each treating a separate lobe of the liver. The physician wrote two prescriptions, one for each lobe. One lobe required 10 mCi, in which the entire 10 mCi dose was delivered. The second prescribed dose was for 7 mCi. Upon performing residual measurements, it was discovered that the delivered dose was 28 percent less than the 7mCi specified in the written directive. There were no equipment malfunctions reported, nor were there any medical reasons for the underdose (stasis was not reached). The AU (Authorized User) was notified, as was the referring physician. When considering the organ as a whole, three separate fractions were prescribed, under three separate written directives (34 mCi + 10 mCi +7 mCi), yielding a total dose of 94.44 Gy. The administered dose was 93.94 Gy. The resultant composite differential is 50 rem, with 99.5% of the desired dose administered to the organ. A written report is pending from the licensee. Illinois Item No.: IL180012 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. |