United States Nuclear Regulatory Commission - Protecting People and the Environment

Event Notification Report for April 24, 2012

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
04/23/2012 - 04/24/2012

** EVENT NUMBERS **


47841

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Agreement State Event Number: 47841
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: PINNACLE HEALTH HOSPITALS
Region: 1
City: CAMP HILL State: PA
County:
License #: PA-0037
Agreement: Y
Docket:
NRC Notified By: DAVID ALLARD
HQ OPS Officer: MARK ABRAMOVITZ
Notification Date: 04/17/2012
Notification Time: 10:53 [ET]
Event Date: 04/13/2012
Event Time: [EDT]
Last Update Date: 04/17/2012
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
Person (Organization):
JUDY JOUSTRA (R1DO)
ANGELA MCINTOSH (FSME)

Event Text

AGREEMENT STATE REPORT - RADIOTHERAPY UNDERDOSE

The following report was received via fax:

"On April 13, 2012, a patient was to receive a prescribed dose of 100 mCi of iodine-131 (I-131) for thyroid cancer. Two capsules of I-131 were received from the radiopharmacy in a single vial which was assayed to assure proper dose prior to administering to the patient. The patient was given the contents of the vial for treatment and the treatment was considered complete. The Nuclear Medicine staff prepared the remaining container for return to the radiopharmacy on Monday April 16, 2012. The radiopharmacy picked up the I-131 container and returned it to their facility. Upon inspection of the returned package, the radiopharmacy discovered that one of the two capsules intended for the treatment remained lodged in the vial. The radiopharmacy informed Tristan and the RSO at 12:30 EDT on Monday April 16, 2012. The patient received 50 mCi of the intended 100 mCi dose.

"Patient and referring physician are in the process of being notified. The [PA] Department [of Radiation Protection] plans to do a reactive inspection on April 17, 2012."

PA Event ID: PA120013

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.

Page Last Reviewed/Updated Tuesday, April 24, 2012
Tuesday, April 24, 2012