The following was received from the
Illinois Emergency Management Agency (the Agency) via email:
The RSO [Radiation Safety Officer] called the Agency on July 21, 2021, to report that a patient scheduled to receive Y-90 microsphere therapy (SIR Spheres) for hepatocellular cancer on April 23, 2021, received only 35 percent of the dose prescribed in the written directive. The underdosing was reported as due to a clogged catheter. No personnel or area contamination was reported. The licensee reported that the dose delivered was still a `clinically effective dose' to the patient and was following up to see if any further treatment was planned.
The RSO discovered the underdosing/medical event during an audit he was conducting in Radiation Therapy on July 20, 2021.
Notification to the referring physician was made as required; however, confirmation that notification to the patient was made is pending.
A reactionary inspection will be performed.
Item Number: IL210020
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.