ENS 49093

v t e ENS Event
14:30 Jun 4, 2013
Title	Agreement State Report - Administered Dose Less than Described Dose
Event Description	The following information was obtained from the Commonwealth of Pennsylvania via facsimile: On June 5, 2013 the licensee informed the Department's [PA Department of Environmental Protection] Southeast Regional Office of the Medical Event. The event is reportable within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> per 10 CFR 35.3045(a)(1)(i). Event Description: At approximately 10:30 a.m. [EDT] on June 4, 2013 the SIR-Sphere procedure took place leading to a microcatheter becoming occluded. The licensee replaced catheters and based on residual measurements of original catheter the patient received 57% of the intended dose. Cause of the Event: Microcatheter became occluded. Actions: The licensee is aware of the requirements to notify the patient and referring physician. A reactive inspection will be scheduled and conducted. PA Event Report ID No.: PA130014 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 49093 +/-
Where
Crozier Chester Medical Center Upland, Pennsylvania (NRC Region 1)
License number:	PA-0061
Organization:	Pa Bureau Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+44.03 h1.835 days <br />0.262 weeks <br />0.0603 months <br />)
Opened:	Joseph Melnic 10:32 Jun 6, 2013
NRC Officer:	Howie Crouch
Last Updated:	Jun 6, 2013
49093 - NRC Website
v • d • e

v t e Emergency Notification System
Crozier Chester Medical Center with Agreement State
WEEKMONTHYEAR2013-06-04T14:30:00 [Table view]
[ENS list for Crozier Chester Medical Center]

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