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Event Notification Report for February 13, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
2/12/2019 - 2/13/2019

** EVENT NUMBERS **

Agreement State	Event Number: 53859
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY Licensee: ALEXIAN BROTHERS MEDICAL CENTER Region: 3 City: ELK GROVE VILLAGE State: IL County: License #: !L-01418-01 Agreement: Y Docket: NRC Notified By: GARY FORSEE HQ OPS Officer: OSSY FONT	Notification Date: 02/04/2019 Notification Time: 17:32 [ET] Event Date: 02/04/2019 Event Time: 00:00 [CST] Last Update Date: 02/04/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): ROBERT DALEY (R3DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - UNDERDOSE EXCEEDING 20 PERCENT OF THE PRESCRIBED DOSE

The following was received via email from the state of Illinois:

"Alexian Brothers Medical Center has advised that an attempted intravascular brachytherapy procedure utilizing a Novoste BetaCath System [containing a sealed source of Sr-90] appears to have resulted in a medical event with an underdose exceeding 20 percent of the prescribed dose. The source train was unable to reach the target location after three attempts, stopping approximately 60mm proximal. The source train was retracted without complication after a 'few seconds' during each attempt. The prescribed exposure was 18.4 Gy. The licensee estimates the unintended area receiving dose (aorta) received 0.006 Sv, less than the 0.5 Sv reporting requirement. This matter is being reported due to the fact the intended tissue received less than 20 percent of the intended dose. This event is ongoing and the report will be amended as details become available. This will be reported to NMED today.

"There is no adverse medical consequence expected for the patient."

Item Number: IL 190006

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.

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