Event Notification Report for February 08, 2024

AGREEMENT STATE REPORT - MEDICAL UNDERDOSE

The following is a summary of information received by email from the Illinois Office of Nuclear Safety:

On January 31, 2024, a medical administration of Y-90 microspheres at Rush University Medical Center failed to deliver the intended dose. A patient had been prescribed 34.99 mCi (500 Gy) of yttrium-90 (Y-90) Theraspheres intended for a liver treatment. The post-administration survey indicated a delivered dose of only 23.05 mCi (330 Gy), which was a 34 percent underdose. The patient and physician were notified the day of the treatment. There was no adverse impact on the patient and the patient will not need to be retreated. The administering physician reported significant resistance in the initial and subsequent flushes.
IL NMED Item Number: IL240003
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.

AGREEMENT STATE REPORT - POTENTIALLY DAMAGED GAUGE

The following information was provided by the Colorado Department of Public Health and Environment (the Division) via email:

"On Thursday February 1, 2024, at approximately 1030 MST, the Division was notified of a vehicle collision that resulted in the damage of a portable nuclear gauge (Nuclear Gauge - Troxler 3430 SN: 28355).

"The initial report indicated the Type A package containing the nuclear gauge was thrown from the vehicle and both the package and the gauge sustained damage.

"Colorado State Patrol responded to the scene and determined the nuclear gauge was intact, and it was turned over to the licensee.

"The Department confirmed with the licensee the gauge was able to be secured with the source in the shielded position and the shielding for the sources is not compromised. A leak test is being expedited at this time."

Colorado Event Number: CO 240001