ENS 56695

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v t e ENS Event
04:00 Aug 23, 2023
Title	Medical Event
Event Description	The following information was received via email from the Pennsylvania Department of Environmental Protection (the Department): On August 24, 2023, the licensee informed the Department of an under-dose incident involving cesium-131 (Cs-131). It is reportable per 10 CFR 35.3045(a)(1). On August 23, 2023 a patient received prostate seed therapy with Cs-131. The therapy plan detailed the need for 24 needles with 98 Cs-131 seeds total (1.8U/seed). A total of 107 Cs-131 seeds were received by the facility, based on the pre-plan volume. Devices used in the operation included: Ultrasound - BK Medical, BK 3000, serial number: 2003107; Planning System - Varian, Variseed 9.0, serial number: B29WL33; Stepper and applicator - CIVCO, Classic Stepper, serial number: 02107; MICK Medical, Mick TP applicator. Seed assay was performed with the activity per seed within acceptable regulatory limits. However, after the medical procedure, more than 37 seeds were found unused. According to the plan, the unused number was supposed to be 9. Thus, a total of 70 seeds were implanted. The physician and patient have been informed. The patient received 201.9 mCi (70 seeds) of the 282.6 mCi (98 seeds) prescribed. 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.: PA230023. 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 56695 +/-
Where
Upmc Horizon, Greenville, Pa Greenville, Pennsylvania (NRC Region 1)
License number:	PA-0057
Organization:	Pa Bureau Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+33.05 h1.377 days <br />0.197 weeks <br />0.0453 months <br />)
Opened:	John Chippo 13:03 Aug 24, 2023
NRC Officer:	Donald Norwood
Last Updated:	Aug 24, 2023
56695 - NRC Website
v • d • e

v t e Emergency Notification System
Upmc Horizon, Greenville, Pa with Agreement State
WEEKMONTHYEAR2023-08-23T04:00:00 [Table view]
[ENS list for Upmc Horizon, Greenville, Pa]

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ENS Notification