ENS 45125

v t e ENS Event
04:00 Mar 26, 2009
Title	Agreement State Report - Medical Event Involving an Underdose Due to Technician Error
Event Description	The following information was received via fax: Event Report ID No: PA090015 License No: PA-0082 Licensee: Mercy Fitzgerald Hospital Event date and time: March 26, 2009/time unknown Event location: Mercy Fitzgerald Hospital Lansdowne & Baily Rds., Darby, PA Event type: Medical Event Notifications: A letter dated April 9, 2009 was sent to DEP Event description: Under dose for a Sr-90 eye applicator City, State: Darby, PA Description: PA DEP Bureau of Radiation Protection was notified in writing, dated April 9, 2009, by the Radiation Safety Officer for Mercy Fitzgerald Hospital. An ADCL calibrated Sr-90 ophthalmic applicator was used on a patient for an external eye application for the treatment of pterygium. The guard ring needed to be removed before treatment and was not, hence only delivered 5% of the prescribed dose to the patient. The State has an inspection scheduled and will continue to keep NRC informed of the status of our investigation. 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.

ENS 45125 +/-
Where
Mercy Fitzgerald Hospital Darby, Pennsylvania (NRC Region 1)
License number:	PA-0082
Organization:	Pa Bureau Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+1865 h77.708 days <br />11.101 weeks <br />2.555 months <br />)
Opened:	David J. Allard 21:00 Jun 11, 2009
NRC Officer:	Steve Sandin
Last Updated:	Jun 11, 2009
45125 - NRC Website
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Mercy Fitzgerald Hospital with Agreement State
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