ENS 57086
ENS Event | |
|---|---|
04:00 Jan 31, 2023 | |
| Title | Medical Event |
| Event Description | The following information was provided by the Pennsylvania Department of Environmental Protection Bureau of Radiation Protection (the Department) via email:
On April 19, 2024, the licensee informed the Department of a medical event. It is reportable per 10 CFR 35.3045. On April 19, 2024, the licensee discovered a medical event from January 31, 2023. A patient received a diagnostic scan that was performed using 4 mCi of I-131. This scan was performed without a written directive being prepared. Immediately upon discovery, the authorized users and technologists received training to remind them that they are required to verify the prescribed dosage to be administered against a prepared written directive. The licensees system was modified to remind the employees to verify the prescribed dosage in the written directive against the dosage about to be administered. No harm is expected to the patient. At this time, no other information is available. The Department will update this event as soon as more information is provided.
The following information was provided by the Pennsylvania Department of Environmental Protection Bureau of Radiation Protection (the Department) via email: The Department wishes to retract this event as it does not meet the qualifications for reporting. Notified R1DO (Werkheiser) and NMSS Events Notification via email. PA Event Number: PA240010 A Medical Event may indicate potential problems in a medical facilitys use of radioactive materials. It does not necessarily result in harm to the patient. |
| Where | |
|---|---|
| University Of Pennsylvania Philadelphia, Pennsylvania (NRC Region 1) | |
| License number: | PA-0131 |
| Organization: | Pa Bureau Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+10738.73 h447.447 days <br />63.921 weeks <br />14.71 months <br />) | |
| Opened: | John Chippo 13:44 Apr 22, 2024 |
| NRC Officer: | Adam Koziol |
| Last Updated: | Apr 23, 2024 |
| 57086 - NRC Website
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University of Pennsylvania with Agreement State | |
WEEKMONTHYEARENS 570812024-04-17T04:00:00017 April 2024 04:00:00
[Table view]Agreement State Medical Underdose ENS 566612023-08-05T15:07:0005 August 2023 15:07:00 Agreement State Medical Underdose ENS 570862023-01-31T04:00:00031 January 2023 04:00:00 Agreement State Medical Event ENS 570852022-12-29T04:00:00029 December 2022 04:00:00 Agreement State Medical Event ENS 570842022-12-28T04:00:00028 December 2022 04:00:00 Agreement State Medical Event ENS 558892022-05-04T04:00:0004 May 2022 04:00:00 Agreement State Underdose ENS 558512022-04-18T04:00:00018 April 2022 04:00:00 Agreement State Patient Underdose ENS 553372021-07-02T04:00:0002 July 2021 04:00:00 Agreement State Patient Under Dose ENS 549642020-10-20T04:00:00020 October 2020 04:00:00 Agreement State Missing Licensed Material ENS 534302018-05-25T04:00:00025 May 2018 04:00:00 Agreement State En Revision Imported Date 10/15/2018 ENS 525042017-01-19T05:00:00019 January 2017 05:00:00 Agreement State Agreement State Report - Received Dose Less than Prescribed Dose ENS 524572016-12-20T05:00:00020 December 2016 05:00:00 Agreement State Agreement State Report - Medical Underdose ENS 483032012-09-11T04:00:00011 September 2012 04:00:00 Agreement State Agreement State Report - Patient Underexposure Using Yttrium-90 Sir-Spheres Treatment ENS 482292012-08-23T04:00:00023 August 2012 04:00:00 Agreement State Agreement State Report - Patient Underexposure Using Yttrium-90 Sir-Spheres Treatment ENS 481372012-07-26T04:00:00026 July 2012 04:00:00 Agreement State Agreement State Report - Medical Event Involving an Underdose with Yttrium-90 Spheres ENS 477632012-03-20T04:00:00020 March 2012 04:00:00 Agreement State Agreement State Report - Underdose During Liver Disease Treatment ENS 474352011-11-10T12:00:00010 November 2011 12:00:00 Agreement State Agreement State Report - Underdosage of Theraspheres ENS 461012010-07-07T04:00:0007 July 2010 04:00:00 Agreement State Agreement State Report - Delivered Dose Differed from the Prescribed Dose by Greater than 50% ENS 457272010-01-21T05:00:00021 January 2010 05:00:00 Agreement State Agreement State Report - Brachytherapy Implants Outside of the Intended Treatment Area 2024-04-17T04:00:00 | |