ENS Event | |
|---|---|
05:00 Nov 15, 2017 | |
| Title | Agreement State Report - Incorrect Written Directive for Liver Patient |
| Event Description | The following report was received from the Pennsylvania Bureau of Radiation Protection via facsimile:
The event involved a patient who was scheduled to be treated with 16 mCi of Y-90 SirSpheres to the left lobe of the liver. The written directive (WD), however, was incorrectly written for the right lobe of the liver. The authorized user (AU) did in fact deliver the correct dose to the correct lobe and the discrepancy was only noticed after the procedure was complete. No harm is expected as the patient received the intended dose to the correct location. The cause of the event was noted as human error resulting from: (1) Failure of the AU to indicate the correct treatment site on the WD. (2) Failure of the AU to forward documentation of the pre-therapy information to the RSO (or designee) prior to the therapy. (3) Failure of clinical staff to identify the discrepancy on the WD during the patient time out just before implantation of the microspheres. Corrective actions include: Before drawing up the dose/activity in Nuclear Medicine (and preferably before the dose/activity is ordered from the manufacturer), the AU must forward pre-therapy documentation (WD, pre-post therapy worksheet, etc.) to the RSO (or designee) to ensure documentation is correct/appropriate. The Department [Pennsylvania Bureau of Radiation Protection] will perform a reactive inspection. The licensee will update their procedure to include additional checks for the written directive. Event Report ID No: PA 170016 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 | |
|---|---|
| Geisinger Health System Danville, Pennsylvania (NRC Region 1) | |
| License number: | Pa170016 |
| Organization: | Pa Bureau Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+8.42 h0.351 days <br />0.0501 weeks <br />0.0115 months <br />) | |
| Opened: | David J. Allard 13:25 Nov 15, 2017 |
| NRC Officer: | Jeff Herrera |
| Last Updated: | Nov 15, 2017 |
| 53073 - NRC Website | |
Geisinger Health System with Agreement State | |
WEEKMONTHYEARENS 563192023-01-11T05:00:00011 January 2023 05:00:00
[Table view]Agreement State Patient Underdose ENS 553762021-07-22T04:00:00022 July 2021 04:00:00 Agreement State Patient Under Dose ENS 530732017-11-15T05:00:00015 November 2017 05:00:00 Agreement State Agreement State Report - Incorrect Written Directive for Liver Patient ENS 515902015-12-04T05:00:0004 December 2015 05:00:00 Agreement State Agreement State Report - Delivered Dose of Yttrium-90 Less than Prescribed Dose 2023-01-11T05:00:00 | |