ENS 54385

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v t e ENS Event
05:00 Nov 8, 2019
Title	Agreement State Report - Dose Delivered Differs by More than 20 Percent
Event Description	The following was received from the Pennsylvania Department of Environmental Protection (DEP; the Department) via email: The Department received initial verbal notification from a licensee on November 8, 2019 of a possible reportable event with a detailed report on November 13, 2019 that on November 8, 2019 a reportable event occurred during an eye plaque implant (Theragenics model AgX100) containing 13 lodine-125 seeds. The seed activity was 3.728 mCi per seed for a total activity of 48.46 mCi. The prescribed dose was 8,500 rad with a planned treatment time of 101 hours0.00117 days <br />0.0281 hours <br />1.669974e-4 weeks <br />3.84305e-5 months <br />. The implant was placed at 0745 [EDT] on 11/8/19. At approximately 0815 the patient complained of excessive pain. It is believed that the eye plaque had become dislodged from its proper position. It was removed at 1731 the same day. The licensee initial worst-case dose estimate to the normal sclera, conjunctiva and cornea is 1,899 rad at a depth of 1 mm for an 8.5 hour5.787037e-5 days <br />0.00139 hours <br />8.267196e-6 weeks <br />1.9025e-6 months <br /> exposure. The dose at 2mm for this same time period is 1,425 rad. Both the patient and surgeon were notified. The effects on the patient are currently being evaluated. The DEP will update this event as soon as more information is provided. Event Report ID No: PA190027 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 54385 +/-
Where
West Penn Allegheny Health System Inc Pittsburg, Pennsylvania (NRC Region 1)
License number:	PA-0031
Organization:	Pa Bureau Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+149.67 h6.236 days <br />0.891 weeks <br />0.205 months <br />)
Opened:	John Chippo 10:40 Nov 14, 2019
NRC Officer:	Ossy Font
Last Updated:	Nov 15, 2019
54385 - NRC Website
v • d • e

v t e Emergency Notification System
West Penn Allegheny Health System Inc with Agreement State
WEEKMONTHYEAR2019-11-08T05:00:00 [Table view]
[ENS list for West Penn Allegheny Health System Inc]

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