Event Notification Report for July 29, 2009
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
07/28/2009 - 07/29/2009
EVENT NUMBERS
45241
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
!!!!! THIS EVENT HAS BEEN RETRACTED !!!!!
General Information or Other
Event Number: 45241
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: LEHIGH VALLEY HOSPITAL
Region: 1
City: BETHLEHEM State: PA
County:
License #: PA0264
Agreement: Y
Docket:
NRC Notified By: DAVE ALLARD
HQ OPS Officer: VINCE KLCO
Licensee: LEHIGH VALLEY HOSPITAL
Region: 1
City: BETHLEHEM State: PA
County:
License #: PA0264
Agreement: Y
Docket:
NRC Notified By: DAVE ALLARD
HQ OPS Officer: VINCE KLCO
Notification Date: 08/03/2009
Notification Time: 20:10 [ET]
Event Date: 07/29/2009
Event Time: 00:00 [EDT]
Last Update Date: 08/28/2009
Notification Time: 20:10 [ET]
Event Date: 07/29/2009
Event Time: 00:00 [EDT]
Last Update Date: 08/28/2009
Emergency Class: NON EMERGENCY
10 CFR Section:
10 CFR Section:
Person (Organization):
MEL GRAY (R1DO)
CHRISTEPHER MCKENNEY (FSME)
MEL GRAY (R1DO)
CHRISTEPHER MCKENNEY (FSME)
AGREEMENT STATE REPORT - IMPROPER TREATMENT
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.
* * * RETRACTION FROM PENNSYLVANIA (ALLARD) TO CROUCH VIA FAX @ 2116 EDT ON 8/28/09 * * *
"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."
Notified R1DO (White) and FSME EO (Suber).
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.
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.
* * * RETRACTION FROM PENNSYLVANIA (ALLARD) TO CROUCH VIA FAX @ 2116 EDT ON 8/28/09 * * *
"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."
Notified R1DO (White) and FSME EO (Suber).
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.