Event Notification Report for April 14, 2023
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
04/13/2023 - 04/14/2023
EVENT NUMBERS
56741
56741
Agreement State
Event Number: 56741
Rep Org: Illinois Emergency Mgmt. Agency
Licensee: Advocate Christ Hospital and Medical Center
Region: 3
City: Oak Lawn State: IL
County:
License #: IL-01720-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Kerby Scales
Licensee: Advocate Christ Hospital and Medical Center
Region: 3
City: Oak Lawn State: IL
County:
License #: IL-01720-01
Agreement: Y
Docket:
NRC Notified By: Gary Forsee
HQ OPS Officer: Kerby Scales
Notification Date: 09/15/2023
Notification Time: 14:38 [ET]
Event Date: 04/14/2023
Event Time: 00:00 [CDT]
Last Update Date: 09/15/2023
Notification Time: 14:38 [ET]
Event Date: 04/14/2023
Event Time: 00:00 [CDT]
Last Update Date: 09/15/2023
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Szwarc, Dariusz (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Szwarc, Dariusz (R3DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE - PATIENT UNDERDOSE
The following information was received from the state of Illinois via email:
"During the course of a routine inspection at the licensee's facility on 9/14/23, inspectors discovered an underdose of a TheraSphere Y-90 treatment performed on 4/14/2023. A patient was receiving treatment for two different liver segments. The first TheraSphere dose to liver segment 3 was prescribed at 200 Gy and the patient only received 150 Gy (75 percent of the intended dose). A second written directive for segment two was successfully delivered (200 Gy prescribed and 194 Gy delivered). At the bottom of the segment 3 written directive an AMP [accredited medical practitioner] wrote 'Due to possible air in tubing, dose to segment 3 was slightly underdosed. Cumulative dose to both segments is 86 percent of [prescribed]'. Inspectors informed the licensee that each written directive is a stand alone document and that this would qualify as a medical event.
"On 9/15/23, the authorized user [AU] physician advised there was no adverse impact to the patient. The licensee advised the referring physician and was working to contact the patient. The AU determined the dose was medically sufficient. The licensee is aware of the 15 day reporting requirement and a written report is pending."
Illinois Item Number: IL230026
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.
The following information was received from the state of Illinois via email:
"During the course of a routine inspection at the licensee's facility on 9/14/23, inspectors discovered an underdose of a TheraSphere Y-90 treatment performed on 4/14/2023. A patient was receiving treatment for two different liver segments. The first TheraSphere dose to liver segment 3 was prescribed at 200 Gy and the patient only received 150 Gy (75 percent of the intended dose). A second written directive for segment two was successfully delivered (200 Gy prescribed and 194 Gy delivered). At the bottom of the segment 3 written directive an AMP [accredited medical practitioner] wrote 'Due to possible air in tubing, dose to segment 3 was slightly underdosed. Cumulative dose to both segments is 86 percent of [prescribed]'. Inspectors informed the licensee that each written directive is a stand alone document and that this would qualify as a medical event.
"On 9/15/23, the authorized user [AU] physician advised there was no adverse impact to the patient. The licensee advised the referring physician and was working to contact the patient. The AU determined the dose was medically sufficient. The licensee is aware of the 15 day reporting requirement and a written report is pending."
Illinois Item Number: IL230026
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.