Event Notification Report for January 11, 2023
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
01/10/2023 - 01/11/2023
Agreement State
Event Number: 56272
Rep Org: Illinois Emergency Mgmt. Agency
Licensee: Alexian Brothers Medical Center
Region: 3
City: Elk Grove Village State: IL
County:
License #: IL-01418-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Adam Koziol
Notification Date: 12/14/2022
Notification Time: 17:00 [ET]
Event Date: 12/14/2022
Event Time: 00:00 [CST]
Last Update Date: 01/10/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
Person (Organization):
Ruiz, Robert (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Event Text
EN Revision Imported Date: 1/11/2023
EN Revision Text: AGREEMENT STATE REPORT - PATIENT UNDERDOSE
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
* * * UPDATE ON 01/10/2023 AT 1535 EST FROM GARY FORSEE TO ERNEST WEST * * *
"When initially reported, this was not identified as a stasis case. Both the patient and the referring physician were notified within 24 hours. 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.