Event Notification Report for November 08, 2019
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
11/07/2019 - 11/08/2019
EVENT NUMBERS
54385
Agreement State
Event Number: 54385
Rep Org: PA BUREAU OF RADIATION PROTECTION
Licensee: WEST PENN ALLEGHENY HEALTH SYSTEM INC
Region: 1
City: PITTSBURG State: PA
County:
License #: PA-0031
Agreement: Y
Docket:
NRC Notified By: JOHN CHIPPO
HQ OPS Officer: OSSY FONT
Licensee: WEST PENN ALLEGHENY HEALTH SYSTEM INC
Region: 1
City: PITTSBURG State: PA
County:
License #: PA-0031
Agreement: Y
Docket:
NRC Notified By: JOHN CHIPPO
HQ OPS Officer: OSSY FONT
Notification Date: 11/14/2019
Notification Time: 10:40 [ET]
Event Date: 11/08/2019
Event Time: 00:00 [EST]
Last Update Date: 11/15/2019
Notification Time: 10:40 [ET]
Event Date: 11/08/2019
Event Time: 00:00 [EST]
Last Update Date: 11/15/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
FRANK ARNER (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
FRANK ARNER (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - DOSE DELIVERED DIFFERS BY MORE THAN 20 PERCENT
The following was received from the Pennsylvania Department of Environmental Protection (DEP; the Department) via email:
"The Department received initial verbal notification from a licensee on November 8, 2019 of a possible reportable event with a detailed report on November 13, 2019 that on November 8, 2019 a reportable event occurred during an eye plaque implant (Theragenics model AgX100) containing 13 lodine-125 seeds. The seed activity was 3.728 mCi per seed for a total activity of 48.46 mCi. The prescribed dose was 8,500 rad with a planned treatment time of 101 hours. The implant was placed at 0745 [EDT] on 11/8/19. At approximately 0815 the patient complained of excessive pain. It is believed that the eye plaque had become dislodged from its proper position. It was removed at 1731 the same day. The licensee initial worst-case dose estimate to the normal sclera, conjunctiva and cornea is 1,899 rad at a depth of 1 mm for an 8.5 hour exposure. The dose at 2mm for this same time period is 1,425 rad. Both the patient and surgeon were notified. The effects on the patient are currently being evaluated. The DEP will update this event as soon as more information is provided."
Event Report ID No: PA190027
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 was received from the Pennsylvania Department of Environmental Protection (DEP; the Department) via email:
"The Department received initial verbal notification from a licensee on November 8, 2019 of a possible reportable event with a detailed report on November 13, 2019 that on November 8, 2019 a reportable event occurred during an eye plaque implant (Theragenics model AgX100) containing 13 lodine-125 seeds. The seed activity was 3.728 mCi per seed for a total activity of 48.46 mCi. The prescribed dose was 8,500 rad with a planned treatment time of 101 hours. The implant was placed at 0745 [EDT] on 11/8/19. At approximately 0815 the patient complained of excessive pain. It is believed that the eye plaque had become dislodged from its proper position. It was removed at 1731 the same day. The licensee initial worst-case dose estimate to the normal sclera, conjunctiva and cornea is 1,899 rad at a depth of 1 mm for an 8.5 hour exposure. The dose at 2mm for this same time period is 1,425 rad. Both the patient and surgeon were notified. The effects on the patient are currently being evaluated. The DEP will update this event as soon as more information is provided."
Event Report ID No: PA190027
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.