ENS Event | |
|---|---|
06:00 Dec 14, 2022 | |
| Title | Patient Underdose |
| Event Description | The following information was provided by the Illinois Emergency Management Agency (The Agency) via email:
The Agency was contacted on 12/14/22 by the medical physicist for Alexian Brothers Medical Center to advise that a Y-90 microsphere administration conducted that morning resulted in a reportable under dose. The administered amount was 20.4 percent lower than that specified in the written directive. This was not a stasis case. The licensee has tried multiple times, but has so far been unable to reach the patient for notification. The referring physician has been notified. Agency inspectors have gathered preliminary information but will conduct a reactionary site visit on Tuesday, 12/20/2022. More information will be provided once it becomes available. Illinois Event Number: IL220043
When initially reported, this was not identified as a stasis case. Both the patient and the referring physician were notified within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />. Agency inspectors conducted a reactionary site visit on 12/20/2022. Upon further discussion and investigation, the authorized user (AU) and authorized medical physicist (AMP) believe the procedure may have reached stasis. The AMP acknowledged that additional training needed to be provided to the treatment team regarding procedures reaching stasis. The licensee determined the root cause to be failure to identify stasis. Agency inspectors determined the potential root cause as a failure to follow procedures and lack of sufficient training to the newly hired AU regarding stasis. This incident and the licensee's procedures will be reviewed during the next routine inspection. This matter may be considered closed. Notified R3DO (Edwards) and NMSS Event Notifications via email. 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 | |
|---|---|
| Alexian Brothers Medical Center Elk Grove Village, Illinois (NRC Region 3) | |
| License number: | IL-01418-01 |
| Organization: | Illinois Emergency Mgmt. Agency |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+11 h0.458 days <br />0.0655 weeks <br />0.0151 months <br />) | |
| Opened: | Gary Forsee 17:00 Dec 14, 2022 |
| NRC Officer: | Adam Koziol |
| Last Updated: | Jan 10, 2023 |
| 56272 - NRC Website | |
Alexian Brothers Medical Center with Agreement State | |
WEEKMONTHYEARENS 562722022-12-14T06:00:00014 December 2022 06:00:00
[Table view]Agreement State Patient Underdose ENS 541402019-07-01T05:00:0001 July 2019 05:00:00 Agreement State Agreement State Report - Medical Event ENS 538592019-02-04T06:00:0004 February 2019 06:00:00 Agreement State Agreement State Report - Underdose Exceeding 20 Percent of the Prescribed Dose ENS 535312015-05-14T05:00:00014 May 2015 05:00:00 Agreement State Agreement State Report - Brachytherapy Source Did Not Fully Retract 2022-12-14T06:00:00 | |