ENS Event | |
|---|---|
06:00 Mar 9, 2022 | |
| Title | Underdose to Patient |
| Event Description | The following information was provided by the Illinois Emergency Management Agency (the Agency) via email:
The radiation safety officer (RSO) for Elmhurst Hospital contacted the Agency on 3/10/22 to advise of a Y-90 microsphere administration in which the patient received only 54 percent of the prescribed dose. The administration occurred on the morning of 3/9/22. The physician felt the delivered dose was clinically effective and no further treatment is planned. No adverse patient impacts are expected. The referring physician and patient were notified as required. Agency staff have requested copies of the written directive and associated documentation as details regarding the prescribed activity were not immediately available. Of note, the RSO advised that the authorized user felt resistance during administration and discontinued the procedure. Microspheres were reportedly observed `clumped' within the first two inches of the delivery catheter. A second, smaller vial was obtained and the written directive modified. No contamination or other issues were identified. The Agency will dispatch inspectors, likely at the beginning of next week, to review the procedure and determine root cause. Compliance with Agency regulations regarding modification to a written directive will be reviewed. This matter will be reported under NMED number IL220008. 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 | |
|---|---|
| Elmhurst Hospital Elmhurst, Illinois (NRC Region 3) | |
| License number: | IL-01612-01 |
| Organization: | Illinois Emergency Mgmt. Agency |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+35.17 h1.465 days <br />0.209 weeks <br />0.0482 months <br />) | |
| Opened: | Gary Forsee 17:10 Mar 10, 2022 |
| NRC Officer: | Dan Livermore |
| Last Updated: | Mar 10, 2022 |
| 55781 - NRC Website | |
Elmhurst Hospital with Agreement State | |
WEEKMONTHYEARENS 559702022-06-29T15:00:00029 June 2022 15:00:00
[Table view]Agreement State Medical Event ENS 557812022-03-09T06:00:0009 March 2022 06:00:00 Agreement State Underdose to Patient 2022-06-29T15:00:00 | |