ENS Event | |
|---|---|
05:00 Aug 24, 2021 | |
| Title | |
| Event Description | The following information was obtained from the Illinois Emergency Management Agency (Agency) via email:
The licensee's radiation safety officer contacted the Agency to advise that a patient scheduled to receive Y-90 microsphere therapy (SirSpheres) for hepatocellular cancer on August 24, 2021, received only 77% of the dose prescribed in the written directive. This administration called for only 16.2 mCi of activity. The licensee's radiation safety officer is reviewing the delivery system as well as the specifics of the administration to determine root cause. The licensee suspects a clogged catheter but is currently investigating. No personnel or area contamination was reported. It is unclear at this point if the referring physician or the patient has been notified. An update has been requested within one hour and Agency staff noted the 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> notification requirement. No untoward medical impact was expected to the patient. Agency inspectors will perform a reactionary inspection on Friday, August 27, 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 Item Number: IL210027 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. |
| Where | |
|---|---|
| Memorial Medical Center Springfield, Illinois (NRC Region 3) | |
| License number: | IL-01343-01 |
| Organization: | Illinois Emergency Mgmt. Agency |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+10.1 h0.421 days <br />0.0601 weeks <br />0.0138 months <br />) | |
| Opened: | Gary Forsee 15:06 Aug 24, 2021 |
| NRC Officer: | Thomas Kendzia |
| Last Updated: | Aug 24, 2021 |
| 55428 - NRC Website | |
Memorial Medical Center with Agreement State | |
WEEKMONTHYEARENS 554282021-08-24T05:00:00024 August 2021 05:00:00
[Table view]Agreement State Underdose 2021-08-24T05:00:00 | |