ENS 53073

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v t e ENS Event
05:00 Nov 15, 2017
Title	Agreement State Report - Incorrect Written Directive for Liver Patient
Event Description	The following report was received from the Pennsylvania Bureau of Radiation Protection via facsimile: The event involved a patient who was scheduled to be treated with 16 mCi of Y-90 SirSpheres to the left lobe of the liver. The written directive (WD), however, was incorrectly written for the right lobe of the liver. The authorized user (AU) did in fact deliver the correct dose to the correct lobe and the discrepancy was only noticed after the procedure was complete. No harm is expected as the patient received the intended dose to the correct location. The cause of the event was noted as human error resulting from: (1) Failure of the AU to indicate the correct treatment site on the WD. (2) Failure of the AU to forward documentation of the pre-therapy information to the RSO (or designee) prior to the therapy. (3) Failure of clinical staff to identify the discrepancy on the WD during the patient time out just before implantation of the microspheres. Corrective actions include: Before drawing up the dose/activity in Nuclear Medicine (and preferably before the dose/activity is ordered from the manufacturer), the AU must forward pre-therapy documentation (WD, pre-post therapy worksheet, etc.) to the RSO (or designee) to ensure documentation is correct/appropriate. The Department [Pennsylvania Bureau of Radiation Protection] will perform a reactive inspection. The licensee will update their procedure to include additional checks for the written directive. Event Report ID No: PA 170016 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 53073 +/-
Where
Geisinger Health System Danville, Pennsylvania (NRC Region 1)
License number:	PA170016
Organization:	Pa Bureau Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+8.42 h0.351 days <br />0.0501 weeks <br />0.0115 months <br />)
Opened:	David J. Allard 13:25 Nov 15, 2017
NRC Officer:	Jeff Herrera
Last Updated:	Nov 15, 2017
53073 - NRC Website
v • d • e

v t e Emergency Notification System
Geisinger Health System with Agreement State
WEEKMONTHYEAR2023-01-11T05:00:00 [Table view]
[ENS list for Geisinger Health System]

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