ENS Event | |
|---|---|
04:00 Mar 22, 2017 | |
| Title | Agreement State Report - Written Directive Incorrectly Identified the Target Organ |
| Event Description | The following information was received from the Commonwealth of Virginia via fax:
On March 31, 2017 the licensee notified the Virginia Office of Radiological Health (ORH) that an eye plaque therapy procedure was not performed in accordance with the procedure's written directive. The plaque was installed on the patient's right eye on March 22 and removed on March 31. The source, 38.8 mCi of l-125, delivered a dose of 85 Gy to the right eye. The right eye was the intended treatment location but the written directive incorrectly identified the target organ as the left eye. The disagreement between the written directive and the treatment location meets the definition of a medical event even though the correct target organ was treated. ORH will review the licensee's written report and determine additional actions to be taken. Event Report ID No.: VA-17-004 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 | |
|---|---|
| University Of Virginia Office Of Environmental Health And Sa Charlottesville, Virginia (NRC Region 1) | |
| License number: | 540-248-1 |
| Organization: | Virginia Rad Materials Program |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+300.12 h12.505 days <br />1.786 weeks <br />0.411 months <br />) | |
| Opened: | Charles Coleman 16:07 Apr 3, 2017 |
| NRC Officer: | Steve Sandin |
| Last Updated: | Apr 3, 2017 |
| 52660 - NRC Website | |
University Of Virginia Office Of Environmental Health And Sa with Agreement State | |
WEEKMONTHYEARENS 526602017-03-22T04:00:00022 March 2017 04:00:00
[Table view]Agreement State Agreement State Report - Written Directive Incorrectly Identified the Target Organ 2017-03-22T04:00:00 | |