ENS 45241: Difference between revisions

v t e ENS Event
04:00 Jul 29, 2009
Title	Agreement State Report - Improper Treatment
Event Description	The following report was sent from the State of Pennsylvania via facsimile: During the patient's treatment, it was determined that the wrong side of the patient's head was being treated [using a gamma knife]. The patient treatment was halted at 47.40 minutes out of the prescribed 55.63 minutes. The prescribed dose was 42.5 Gy to the 50% isodose line. Patient received 34.5 Gy to the 50% isodose. PA DEP [The Pennsylvania Department] Bureau of Radiation Protection was notified in writing, dated July 29, 2009. Their suggestion for improvement is while all treatment team members are present during a 'time out' procedure, to have the patient state the side of his/her lesion or treatment and place an imaging marker to designate the treatment side. The State [of Pennsylvania] will continue to keep NRC informed of the status of the investigation. Pennsylvania Report PA090027. * * RETRACTION FROM PENNSYLVANIA (ALLARD) TO CROUCH VIA FAX @ 2116 EDT ON 8/28/09 * * * Regarding the Lehigh Valley Hospital Medical Event (PA090027) reported to the HOO via fax on 8-3-09, please be advised of our [Pennsylvania Department of Environmental Protection] intent to retract this report. Based on our inspection and follow-up with the licensee, it was determined that, although the initial written directive was prepared in error, all radiation treatments received by the patient were, in fact, delivered in accordance with a written directive. However, the licensee has taken corrective actions to avoid a similar event occurring in the future. Notified R1DO (White) and FSME EO (Suber). 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 45241 +/- *RETRACTED*
Where
Lehigh Valley Hospital Bethlehem, Pennsylvania (NRC Region 1)
License number:	PA0264
Organization:	Pa Bureau Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+136.17 h5.674 days <br />0.811 weeks <br />0.187 months <br />)
Opened:	Dave Allard 20:10 Aug 3, 2009
NRC Officer:	Vince Klco
Last Updated:	Aug 28, 2009
45241 - NRC Website
v • d • e

v t e Emergency Notification System
Lehigh Valley Hospital with Agreement State
WEEKMONTHYEAR2009-07-29T04:00:00 [Table view]
[ENS list for Lehigh Valley Hospital]

@@ Line 3: / Line 3: @@
 | facility = Lehigh Valley Hospital
 | Organization = Pa Bureau Of Radiation Protection
-| license number = Pa0264
+| license number = PA0264
 | region = 1
 | state = Pennsylvania

ENS 45241: Difference between revisions

Latest revision as of 19:25, 24 November 2018

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ENS 45241: Difference between revisions

Latest revision as of 19:25, 24 November 2018

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