ENS 46022

v t e ENS Event
04:00 Jun 3, 2010
Title	Agreement State Report - High Dose Rate Treatment Administered to an Unintended Area
Event Description	The following report was received via facsimile from the Commonwealth of Pennsylvania: The licensee called the PaDEP [Pennsylvania Department of Environmental Protection] Southcentral Regional Office on the morning of June 16, 2010, to provide a 24-hour verbal notice of a medical event. The licensee also notified the patient and attending physician on June 16, 2010. The event involves a dosage that differs from the intended dose by greater than 20%, consequently requiring a 24-hour report per 10 CFR 35.3045. On June 3, 2010, a patient was undergoing HDR [High Dose Rate] treatment for ovarian cancer. The area to be treated was incorrectly entered into the HDR computer and resulted in the patient receiving a dose to an unintended area. This event was discovered during the second fraction of treatment on June 15, 2010. Cause of the event was human error. The Department is awaiting more event details at this time and plans to send regional staff to conduct an inspection on June 21, 2010. Final event details will be communicated in a NMED report. PA Event No.: PA100012 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 46022 +/-
Where
Lancaster General Hospital Lancaster, Pennsylvania (NRC Region 1)
License number:	PA-0233
Organization:	Pa Bureau Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+345.85 h14.41 days <br />2.059 weeks <br />0.474 months <br />)
Opened:	Joseph Melnic 13:51 Jun 17, 2010
NRC Officer:	Dong Park
Last Updated:	Jun 17, 2010
46022 - NRC Website
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v t e Emergency Notification System
Lancaster General Hospital with Agreement State
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