Event Notification Report for December 29, 2022
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
12/28/2022 - 12/29/2022
EVENT NUMBERS
57085
57085
Agreement State
Event Number: 57085
Rep Org: PA Bureau of Radiation Protection
Licensee: University of Pennsylvania
Region: 1
City: Philadelphia State: PA
County:
License #: PA-0131
Agreement: Y
Docket:
NRC Notified By: John Chippo
HQ OPS Officer: Adam Koziol
Licensee: University of Pennsylvania
Region: 1
City: Philadelphia State: PA
County:
License #: PA-0131
Agreement: Y
Docket:
NRC Notified By: John Chippo
HQ OPS Officer: Adam Koziol
Notification Date: 04/22/2024
Notification Time: 13:44 [ET]
Event Date: 12/29/2022
Event Time: 00:00 [EDT]
Last Update Date: 04/23/2024
Notification Time: 13:44 [ET]
Event Date: 12/29/2022
Event Time: 00:00 [EDT]
Last Update Date: 04/23/2024
Emergency Class: Non Emergency
10 CFR Section:
Agreement State
10 CFR Section:
Agreement State
Person (Organization):
Werkheiser, Dave (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
Werkheiser, Dave (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - MEDICAL EVENT
The following information was provided by the Pennsylvania Department of Environmental Protection Bureau of Radiation Protection (the Department) via email:
"On April 19, 2024, the licensee informed the Department of a medical event. It is reportable per 10 CFR 35.3045.
"On April 19, 2024, the licensee discovered a medical event from December 29, 2022. A patient received a diagnostic scan that was performed using 1 mCi of I-131. This scan was performed without a written directive being prepared. Immediately upon discovery, the authorized users and technologists received training to remind them that they are required to verify the prescribed dosage to be administered against a prepared written directive. The licensee's system was modified to remind the employees to verify the prescribed dosage in the written directive against the dosage about to be administered. No harm is expected to the patient.
"At this time, no other information is available. The Department will update this event as soon as more information is provided."
* * * RETRACTION ON 4/23/24 AT 0740 EDT FROM JOHN CHIPPO TO BILL GOTT * * *
The following information was provided by the Pennsylvania Department of Environmental Protection Bureau of Radiation Protection (the Department) via email:
"The Department wishes to retract this event as it does not meet the qualifications for reporting."
Notified R1DO (Werkheiser) and NMSS Events Notification via email.
PA Event Number: PA240009
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 provided by the Pennsylvania Department of Environmental Protection Bureau of Radiation Protection (the Department) via email:
"On April 19, 2024, the licensee informed the Department of a medical event. It is reportable per 10 CFR 35.3045.
"On April 19, 2024, the licensee discovered a medical event from December 29, 2022. A patient received a diagnostic scan that was performed using 1 mCi of I-131. This scan was performed without a written directive being prepared. Immediately upon discovery, the authorized users and technologists received training to remind them that they are required to verify the prescribed dosage to be administered against a prepared written directive. The licensee's system was modified to remind the employees to verify the prescribed dosage in the written directive against the dosage about to be administered. No harm is expected to the patient.
"At this time, no other information is available. The Department will update this event as soon as more information is provided."
* * * RETRACTION ON 4/23/24 AT 0740 EDT FROM JOHN CHIPPO TO BILL GOTT * * *
The following information was provided by the Pennsylvania Department of Environmental Protection Bureau of Radiation Protection (the Department) via email:
"The Department wishes to retract this event as it does not meet the qualifications for reporting."
Notified R1DO (Werkheiser) and NMSS Events Notification via email.
PA Event Number: PA240009
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.