ENS 51804

v t e ENS Event
04:00 Mar 15, 2016
Title	Agreement State Report - Medical Underdose
Event Description	The following was received from Pennsylvania via email: On March 15, 2016 a written directive for 18.1 mCi of yttrium-90 (Y-90) was written by the authorized user (AU) and referring physician for this procedure. The entire content of the syringe was injected and the residual activity in the vial measured 13.3 mCi, or 73.5% of the prescribed dose. No harm is expected to the patient. A different AU wrote the initial written directive based on incorrect dose calculation. The discrepancy was not realized until after the administration was completed. A reactive inspection is planned by the Department [PA Bureau of Radiation Protection]. More information will be provided upon receipt. PA Incident # PA160010 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.

ENS 51804 +/-
Where
Penn State Hershey Medical Center Hershey, Pennsylvania (NRC Region 1)
License number:	PA-0127
Organization:	Pa Bureau Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+79.72 h3.322 days <br />0.475 weeks <br />0.109 months <br />)
Opened:	Joseph Melnic 11:43 Mar 18, 2016
NRC Officer:	Daniel Mills
Last Updated:	Mar 18, 2016
51804 - NRC Website
v • d • e

v t e Emergency Notification System
Penn State Hershey Medical Center with Agreement State
WEEKMONTHYEAR2016-03-15T04:00:00 [Table view]
[ENS list for Penn State Hershey Medical Center]

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