ENS Event | |
|---|---|
04:00 Aug 21, 2012 | |
| Title | Agreement State - Radiation Treatment Overdose Resulting from a Potential Generic Issue |
| Event Description | The following information was provided by the State of Pennsylvania via facsimile:
On Monday, August 20, 2012, the licensee informed the Pennsylvania Department of Environmental Protection's Southcentral Regional Office of a medical event which occurred the same day. It is reportable within 24-hours under 10 CFR 35.3045(a)(1)(iii). During the first fraction of radiation therapy treatment, using a Nucletron Corporation microSelectron HDR (High Dose Rate) Model 106.990 remote afterloader, the unit's treatment planning software malfunctioned, resulting in an overdose to the patient of approximately 76.5%. Facility staff also failed to complete a required worksheet which may have alerted the Authorized User to the dosage difference prior to treatment. A total dose of 600 cGy (rad) was delivered instead of the prescribed 340 cGy (rad). The patient was notified on the same day, while the referring physician was notified the following day. The treating physician anticipates no effect to the patient, however, dose reconstruction is currently in progress. We believe this incident also qualifies the event as an Abnormal Occurrence. Cause of the event is equipment malfunction and human error. Licensee is contacting a service provider for the HDR unit to investigate the incident, and if needed, repair the equipment. The Pennsylvania Department of Environmental Protection will be evaluating possible generic implications and plans to do a reactive inspection as soon as possible. PA Event Report No: PA120025 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. |
| 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:+12.45 h0.519 days <br />0.0741 weeks <br />0.0171 months <br />) | |
| Opened: | David Allard 16:27 Aug 21, 2012 |
| NRC Officer: | John Shoemaker |
| Last Updated: | Aug 21, 2012 |
| 48218 - NRC Website | |
York Hospital with Agreement State | |
WEEKMONTHYEARENS 543462019-10-23T04:00:00023 October 2019 04:00:00
[Table view]Agreement State Incorrect Brachytherapy Seed Set Used for Implantation ENS 496862013-12-27T05:00:00027 December 2013 05:00:00 Agreement State Agreement State Report - Nuclear Medicine Administered to Wrong Patient ENS 482182012-08-21T04:00:00021 August 2012 04:00:00 Agreement State Agreement State - Radiation Treatment Overdose Resulting from a Potential Generic Issue 2019-10-23T04:00:00 | |