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The following was received from the Illino … The following was received from the Illinois Emergency Management Agency (the Agency) via email:</br>Representatives of Elmhurst Hospital (RML IL-01612-01) contacted the Agency at approximately 1230 CDT today, 6/29/22, to report a Y-90 Theraspheres administration that took place on 6/29/22 (approximately 1000 CDT) which resulted in 100 percent of the dose prescribed not being delivered. The pre and post surveys of the vial and delivery system were nearly identical, supporting the licensee's assertion that no microspheres were delivered. The patient was surveyed post-administration and was at background. While contamination was identified on the draping, it resulted from the disconnection of the delivery system when the administration was halted. No contamination was identified on the patient.</br>Microspheres were observed clustered at the hub and none beyond. The licensee claims there were no kinks and the manufacturer's checklist was followed to include agitation/flushing. At this time, it is unclear if the patient and referring physician have been notified, but the licensee is aware of the requirement. The licensee is aware of the 15-day written report requirement. The AU ((Authorized User)) will be back in the office on Friday and understands the Agency will need additional information via a reactionary inspection. The Agency is scheduling a reactive inspection and this report will be updated as information becomes available.</br>Illinois Item Number: IL220023</br>* * * UPDATE ON 9/01/2022 AT 1616 EDT FROM LLINOIS EMERGENCY MANAGEMENT AGENCY TO KAREN COTTON VIA E-MAIL* * *</br>The Agency conducted a reactive inspection on 7/1/22. At that time, no indications of root cause could be identified. The licensee's written report was received timely and presented no new information. The delivery kit was returned to the manufacturer for assessment when decayed.</br>Subsequent information was submitted to the Agency for review. The licensee's written report was received timely. Documentation included Gamma camera images of the administration set up kit and catheter which appeared to show activity in the microcatheter. Based on images reviewed, the Agency cannot rule out that some activity may have been delivered to the patient. </br>Due to the contamination, not all of the activity in the waste was able to be accounted for; however, the bulk of activity in the waste indicated that conservatively less than 8.9% of the dosage was delivered.</br>Agency inspectors determined the potential root cause as clumping of microspheres between the D and E lines of the administration kit pending investigation/assessment of the administration kit by the manufacturer. The Agency will continue to monitor additional information provided by the licensee. </br>This matter may be considered closed.</br>Notified R3DO (Hills) and NMSS Event Notification via email.</br>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 necessarily result in harm to the patient
15:00:00, 29 June 2022 +
15:53:00, 29 June 2022 +
15:00:00, 29 June 2022 +
The following was received from the Illino … The following was received from the Illinois Emergency Management Agency (the Agency) via email:</br>Representatives of Elmhurst Hospital (RML IL-01612-01) contacted the Agency at approximately 1230 CDT today, 6/29/22, to report a Y-90 Theraspheres administration that took place on 6/29/22 (approximately 1000 CDT) which resulted in 100 percent of the dose prescribed not being delivered. The pre and post surveys of the vial and delivery system were nearly identical, supporting the licensee's assertion that no microspheres were delivered. The patient was surveyed post-administration and was at background. While contamination was identified on the draping, it resulted from the disconnection of the delivery system when the administration was halted. No contamination was identified on the patient.</br>Microspheres were observed clustered at the hub and none beyond. The licensee claims there were no kinks and the manufacturer's checklist was followed to include agitation/flushing. At this time, it is unclear if the patient and referring physician have been notified, but the licensee is aware of the requirement. The licensee is aware of the 15-day written report requirement. The AU ((Authorized User)) will be back in the office on Friday and understands the Agency will need additional information via a reactionary inspection. The Agency is scheduling a reactive inspection and this report will be updated as information becomes available.</br>Illinois Item Number: IL220023</br>* * * UPDATE ON 9/01/2022 AT 1616 EDT FROM LLINOIS EMERGENCY MANAGEMENT AGENCY TO KAREN COTTON VIA E-MAIL* * *</br>The Agency conducted a reactive inspection on 7/1/22. At that time, no indications of root cause could be identified. The licensee's written report was received timely and presented no new information. The delivery kit was returned to the manufacturer for assessment when decayed.</br>Subsequent information was submitted to the Agency for review. The licensee's written report was received timely. Documentation included Gamma camera images of the administration set up kit and catheter which appeared to show activity in the microcatheter. Based on images reviewed, the Agency cannot rule out that some activity may have been delivered to the patient. </br>Due to the contamination, not all of the activity in the waste was able to be accounted for; however, the bulk of activity in the waste indicated that conservatively less than 8.9% of the dosage was delivered.</br>Agency inspectors determined the potential root cause as clumping of microspheres between the D and E lines of the administration kit pending investigation/assessment of the administration kit by the manufacturer. The Agency will continue to monitor additional information provided by the licensee. </br>This matter may be considered closed.</br>Notified R3DO (Hills) and NMSS Event Notification via email.</br>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 necessarily result in harm to the patient
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00:00:00, 1 September 2022 +
IL-01612-01 +
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11:30:10, 2 September 2022 +
15:53:00, 29 June 2022 +
0.0367 d (0.88 hours, 0.00524 weeks, 0.00121 months) +
15:00:00, 29 June 2022 +
URL"URL" is a <a href="/Special:Types/URL" title="Special:Types/URL">type</a> and predefined property provided by <a rel="nofollow" class="external text" href="https://www.semantic-mediawiki.org/wiki/Help:Special_properties">Semantic MediaWiki</a> to represent URI/URL values.