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.
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. 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 | |
|---|---|
| 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 | |
Lehigh Valley Hospital with Agreement State | |
WEEKMONTHYEARENS 452412009-07-29T04:00:00029 July 2009 04:00:00
[Table view]Agreement State Agreement State Report - Improper Treatment ENS 456562008-07-17T05:00:00017 July 2008 05:00:00 Agreement State Agreement State Report- Medical Overexposure Event 2009-07-29T04:00:00 | |