ENS 54346

v t e ENS Event
04:00 Oct 23, 2019
Title	Incorrect Brachytherapy Seed Set Used for Implantation
Event Description	The following information was received via E-mail: The licensee informed the Department [Pennsylvania Department of Radiation Protection] that a brachytherapy seed set was implanted in the wrong patient. It is reportable per 10 CFR 35.3045(a)(2)(iii)(B). On October 23, 2019, the licensee was performing a permanent brachytherapy during which an incorrect prostate brachytherapy seed set (lsoRay Model CS-1) was brought to the procedure room and 6 Cs-131 seeds were implanted into the prostate of a patient. The procedure was stopped immediately when the error was recognized. The correct seeds were then brought to the operating room and the procedure was completed using the correct seeds. Forty Seven (47) seeds, 85 gray, (3.135 mCi) were prescribed and 3.03 mCi given. The Authorized User notified the urologist and patient this morning (10/24/19). No harm is expected to the patient. The cause of the event is unknown at this time. The Department will perform a reactive inspection. More information will be provided as received. Pennsylvania Event Report ID No: PA190024 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 54346 +/-
Where
York Hospital York, Pennsylvania (NRC Region 1)
License number:	PA-0010
Organization:	Pa Bureau Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+31.85 h1.327 days <br />0.19 weeks <br />0.0436 months <br />)
Opened:	John Chippo 11:51 Oct 24, 2019
NRC Officer:	Donald Norwood
Last Updated:	Oct 24, 2019
54346 - NRC Website
v • d • e

v t e Emergency Notification System
York Hospital with Agreement State
WEEKMONTHYEAR2019-10-23T04:00:00 [Table view]
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