ENS Event | |
|---|---|
05:00 Oct 14, 2024 | |
| Title | Medical Underdose |
| Event Description | The following information was provided by the Illinois Emergency Management Agency (The Agency) via phone and email:
The Agency was contacted by the radiation safety officer (RSO) for Rush University Medical Center, on October 15, 2024, to report that a patient prescribed 66.67 mCi (479 Gy) of Y-90 Theraspheres on October 14, 2024, received only 20.14 mCi (144.7 Gy) of the prescribed dose. The patient has been notified and the RSO is still attempting to notify the referring physician who left on vacation immediately after the procedure. There was no reported adverse impact on the patient and the licensee is still discussing possible retreatment. The administering physician reported significant resistance during the administration and filling of the overflow vial. An investigation remains ongoing. The underdose (69.8 percent deviation between the prescribed and administered dose) meets the criteria as a reportable incident under 32 Illinois administrative code 335.1080. Inspectors will perform a reactive inspection on October 17, 2024. 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 | |
|---|---|
| Rush University Medical Center Chicago, Illinois (NRC Region 3) | |
| License number: | IL-01766-01 |
| Organization: | Illinois Emergency Mgmt. Agency |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+56.1 h2.338 days <br />0.334 weeks <br />0.0768 months <br />) | |
| Opened: | Whitney Cox 13:06 Oct 16, 2024 |
| NRC Officer: | Karen Cotton-Gross |
| Last Updated: | Oct 16, 2024 |
| 57385 - NRC Website | |
Rush University Medical Center with Agreement State | |
WEEKMONTHYEARENS 573852024-10-14T05:00:00014 October 2024 05:00:00
[Table view]Agreement State Medical Underdose ENS 569422024-01-31T06:00:00031 January 2024 06:00:00 Agreement State Medical Underdose ENS 567662023-09-28T05:00:00028 September 2023 05:00:00 Agreement State Underdose to Patient ENS 535602018-08-23T05:00:00023 August 2018 05:00:00 Agreement State Illinois Agreement State Report - Medical Event ENS 465432010-11-23T06:00:00023 November 2010 06:00:00 Agreement State Agreement State Report Involving a Medical Event 2024-10-14T05:00:00 | |