ENS 47404: Difference between revisions

From kanterella

Latest revision as of 18:18, 24 November 2018

v t e ENS Event
19:50 Nov 2, 2011
Title	Agreement State Report - Underdosage of Y-90 Theraspheres
Event Description	The following was received from the Commonwealth of Pennsylvania via fax: Event type: A medical event (ME) involving Y-90 TheraSpheres where the patient received an under-dose of 63%, which is reportable under 10CFR35.3045(a)(1)(ii). Notifications: On November 2, 2011, at 1550, the Department's Southeast Regional Office received notification via phone message about the ME. Event Description: A patient who was being treated with MDS Nordion Y-90 TheraSpheres, received only 37% of the intended dose based on the before and after survey readings of the TheraSphere accoutrements (5.8mR/hr vs. 3.8mR/hr). The licensee is in the process of notifying the patient. No more information is available at this time. Cause of the Event: The licensee suspects that procedural changes led to the problem. Nordion recently changed the procedure to clamp the priming line with a hemostat because the original clamp is hard to manipulate. This was their first procedure using the hemostat. Actions: Nordion has been contacted. The licensee will be submitting a written report within 15 days. The Department plans to do a reactive inspection. Event Report ID No. PA 110033 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 47404 +/-
Where
Eastern Regional Medical Center Philadelphia, Pennsylvania (NRC Region 1)
License number:	PA-0980
Organization:	Pa Bureau Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+14.65 h0.61 days <br />0.0872 weeks <br />0.0201 months <br />)
Opened:	Joe Melnic 10:29 Nov 3, 2011
NRC Officer:	Joe O'Hara
Last Updated:	Nov 3, 2011
47404 - NRC Website
v • d • e

v t e Emergency Notification System
Eastern Regional Medical Center with Agreement State
WEEKMONTHYEAR2019-02-08T05:00:00 [Table view]
[ENS list for Eastern Regional Medical Center]

@@ Line 3: / Line 3: @@
 | facility = Eastern Regional Medical Center
 | Organization = Pa Bureau Of Radiation Protection
-| license number = Pa-0980
+| license number = PA-0980
 | region = 1
 | state = Pennsylvania
@@ Line 16: / Line 16: @@
 | event date = 11/02/2011 15:50 EDT
 | last update date = 11/03/2011
-| title = Agreement State Report - Underdosage Of Y-90 Theraspheres
+| title = Agreement State Report - Underdosage of Y-90 Theraspheres
 | event text = The following was received from the Commonwealth of Pennsylvania via fax:
 Event type: A medical event (ME) involving Y-90 TheraSpheres where the patient received an under-dose of 63%, which is reportable under 10CFR35.3045(a)(1)(ii).