ENS Event | |
|---|---|
04:00 Feb 7, 2008 | |
| Title | Agreement State Report - Medical Dose Not in Accordance with Written Directive |
| Event Description | On Friday April 25, 2008 at approximately 1700 hrs, the Pennsylvania Bureau of Radiation Protection's Central Office Licensing Section was notified by [REDACTED] of a Medical Reportable Event that occurred on February 7, 2008 at Geisinger's Wyoming Valley Hospital located at 1000 East Mountain Drive in Wilkes Barre, PA. (License #37-01421-01; PA-0006) The event was not discovered until Friday April 25, 2008 during a licensee review of Written Directives administered.
Licensee stated that the written directive for an I-131 treatment of a hyperactive thyroid was incorrectly written as 10 microcuries (0.37 MBq). Licensee stated that the nuclear medicine technician either did not read the directive or misread the directive and administered 10 millicuries. Licensee stated that the dose administered was appropriate for the treatment, however, inconsistent with the written directive. The prescribing physician was notified on the date of discovery. Licensee stated that no adverse health effects are expected as a result of this error. The error most likely occurred because the most common prescriptions for this sort of treatment are 10 - 20 mCi (370 - 740 MBq) I-131 and the technician did not recognize that the written directive stated 10 uCi (0.37 MBq). Licensee stated that actions taken to prevent recurrence had not been undertaken at the time of report. Licensee will be sending a written report to PA DEP's SCRO. The above information was reported to [REDACTED] PA DEP BRP Director on 4/28/2008. 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 | |
|---|---|
| Geisinger Wyoming Valley Hospital Wilkes-Barre, Pennsylvania (NRC Region 1) | |
| License number: | PA-0006 |
| Organization: | Pa Bureau Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+1958.25 h81.594 days <br />11.656 weeks <br />2.682 months <br />) | |
| Opened: | Dave Allard 17:15 Apr 28, 2008 |
| NRC Officer: | Mark Abramovitz |
| Last Updated: | Apr 28, 2008 |
| 44173 - NRC Website | |
Geisinger Wyoming Valley Hospital with Agreement State | |
WEEKMONTHYEARENS 441732008-02-07T04:00:0007 February 2008 04:00:00
[Table view]Agreement State Agreement State Report - Medical Dose Not in Accordance with Written Directive 2008-02-07T04:00:00 | |