ENS 52660

v t e ENS Event
04:00 Mar 22, 2017
Title	Agreement State Report - Written Directive Incorrectly Identified the Target Organ
Event Description	The following information was received from the Commonwealth of Virginia via fax: On March 31, 2017 the licensee notified the Virginia Office of Radiological Health (ORH) that an eye plaque therapy procedure was not performed in accordance with the procedure's written directive. The plaque was installed on the patient's right eye on March 22 and removed on March 31. The source, 38.8 mCi of l-125, delivered a dose of 85 Gy to the right eye. The right eye was the intended treatment location but the written directive incorrectly identified the target organ as the left eye. The disagreement between the written directive and the treatment location meets the definition of a medical event even though the correct target organ was treated. ORH will review the licensee's written report and determine additional actions to be taken. Event Report ID No.: VA-17-004 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 52660 +/-
Where
University Of Virginia Office Of Environmental Health And Sa Charlottesville, Virginia (NRC Region 1)
License number:	540-248-1
Organization:	Virginia Rad Materials Program
Reporting

Agreement State
Time - Person (Reporting Time:+300.12 h12.505 days <br />1.786 weeks <br />0.411 months <br />)
Opened:	Charles Coleman 16:07 Apr 3, 2017
NRC Officer:	Steve Sandin
Last Updated:	Apr 3, 2017
52660 - NRC Website
v • d • e

v t e Emergency Notification System
University Of Virginia Office Of Environmental Health And Sa with Agreement State
WEEKMONTHYEAR2017-03-22T04:00:00 [Table view]
[ENS list for University Of Virginia Office Of Environmental Health And Sa]

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