ENS 55716
ENS Event | |
|---|---|
06:00 Jan 27, 2022 | |
| Title | Patient Underdose |
| Event Description | The following information was received from Illinois Emergency Management Agency (Agency) via phone and E-mail:
At 1545 CST on 1/27/2022, the Agency was contacted by Northwestern Memorial Hospital (IL-01037-02) of a potential medical event. No adverse patient impact reported. The administration was able to be completed that same day. This event was reported to the NRC Headquarters Operations Officer (1/28/22) this afternoon. Agency inspectors performed a reactive inspection on 1/28/2022 at Central DuPage Hospital. On 1/27/2022, a written directive to deliver 3.25 GBq Y-90 SIR-Spheres to the right hepatic artery was prepared. The procedure performed that same day was halted prematurely due to an occlusion of microspheres in the delivery line. [Surveys of the delivery equipment indicated no microspheres were delivered to the patient.] To compensate for the underdose, the licensee created two additional written directives and administered two doses of 1.55 GBq Y-90 SIR-Spheres each without incident. The licensee is continuing their investigation into root cause. [Agency will review the investigation results.] Item Number: IL220002 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 | |
|---|---|
| Northwestern Memorial Hospital Chicago, Illinois (NRC Region 3) | |
| License number: | IL-01037-02 |
| Organization: | Illinois Emergency Mgmt. Agency |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+35 h1.458 days <br />0.208 weeks <br />0.0479 months <br />) | |
| Opened: | Robin Muzzalupo 17:00 Jan 28, 2022 |
| NRC Officer: | Thomas Kendzia |
| Last Updated: | Jan 28, 2022 |
| 55716 - NRC Website
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Northwestern Memorial Hospital with Agreement State | |
WEEKMONTHYEARENS 570972024-04-30T05:00:00030 April 2024 05:00:00
[Table view]Agreement State Medical Event ENS 558422022-04-11T05:00:00011 April 2022 05:00:00 Agreement State Patient Received Dose Less than Prescribed ENS 557162022-01-27T06:00:00027 January 2022 06:00:00 Agreement State Patient Underdose ENS 557042021-02-15T06:00:00015 February 2021 06:00:00 Agreement State Patient Underdose ENS 467922011-04-27T05:00:00027 April 2011 05:00:00 Agreement State Agreement State Report - Underdose Due to Clumping in the Delivery Device ENS 448162009-01-29T06:00:00029 January 2009 06:00:00 Agreement State Agreement State Report - Personnel Contamination from I-131 Spill in Hot Lab ENS 423542006-02-21T06:00:00021 February 2006 06:00:00 Agreement State Agreement State - Loss of Iridium Seed Strand Following Medical Treatment 2024-04-30T05:00:00 | |