Event Notification Report for October 23, 2019
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
10/22/2019 - 10/23/2019
EVENT NUMBERS
54346
Agreement State
Event Number: 54346
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: YORK HOSPITAL
Region: 1
City: YORK State: PA
County:
License #: PA-0010
Agreement: Y
Docket:
NRC Notified By: JOHN CHIPPO
HQ OPS Officer: DONALD NORWOOD
Licensee: YORK HOSPITAL
Region: 1
City: YORK State: PA
County:
License #: PA-0010
Agreement: Y
Docket:
NRC Notified By: JOHN CHIPPO
HQ OPS Officer: DONALD NORWOOD
Notification Date: 10/24/2019
Notification Time: 11:51 [ET]
Event Date: 10/23/2019
Event Time: 00:00 [EDT]
Last Update Date: 10/24/2019
Notification Time: 11:51 [ET]
Event Date: 10/23/2019
Event Time: 00:00 [EDT]
Last Update Date: 10/24/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
BRICE BICKETT (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
BRICE BICKETT (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
INCORRECT BRACHYTHERAPY SEED SET USED FOR IMPLANTATION
The following information was received via E-mail:
"The licensee informed the Department [Pennsylvania Department of Radiation Protection] that a brachytherapy seed set was implanted in the wrong patient. It is reportable per 10 CFR 35.3045(a)(2)(iii)(B).
"On October 23, 2019, the licensee was performing a permanent brachytherapy during which an incorrect prostate brachytherapy seed set (lsoRay Model CS-1) was brought to the procedure room and 6 Cs-131 seeds were implanted into the prostate of a patient. The procedure was stopped immediately when the error was recognized. The correct seeds were then brought to the operating room and the procedure was completed using the correct seeds. Forty Seven (47) seeds, 85 gray, (3.135 mCi) were prescribed and 3.03 mCi given. The Authorized User notified the urologist and patient this morning (10/24/19). No harm is expected to the patient.
"The cause of the event is unknown at this time. The Department will perform a reactive inspection. More information will be provided as received."
Pennsylvania Event Report ID No: PA190024
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 information was received via E-mail:
"The licensee informed the Department [Pennsylvania Department of Radiation Protection] that a brachytherapy seed set was implanted in the wrong patient. It is reportable per 10 CFR 35.3045(a)(2)(iii)(B).
"On October 23, 2019, the licensee was performing a permanent brachytherapy during which an incorrect prostate brachytherapy seed set (lsoRay Model CS-1) was brought to the procedure room and 6 Cs-131 seeds were implanted into the prostate of a patient. The procedure was stopped immediately when the error was recognized. The correct seeds were then brought to the operating room and the procedure was completed using the correct seeds. Forty Seven (47) seeds, 85 gray, (3.135 mCi) were prescribed and 3.03 mCi given. The Authorized User notified the urologist and patient this morning (10/24/19). No harm is expected to the patient.
"The cause of the event is unknown at this time. The Department will perform a reactive inspection. More information will be provided as received."
Pennsylvania Event Report ID No: PA190024
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.