ENS Event | |
|---|---|
16:00 Aug 18, 2003 | |
| Title | Patient Exceeded Prescribed Dose. |
| Event Description | A patient was undergoing an intravascular brachytherapy procedure using a Novoste 40 mm. Sr-90 system with a prescribed dose of 23 gray. Due to difficulties retracting the source train to its shielded position, the exposure time was 5.09 minutes (one minute longer than the planned 4.09 minutes). Preliminary estimates indicate that the delivered dose exceeded the prescribed dose by approximately 25 percent. Novoste was notified and a Novoste representative went to the medical facility to investigate. The Novoste system will be sent to Novoste in Georgia for analysis. The licensee continues to investigate and refine the dose calculations and will submit the required written report as soon as possible.
Illinois assigned event number: IL030064. |
| Where | |
|---|---|
| Rush North Medical Center Skokie, Illinois (NRC Region 3) | |
| License number: | IL-01578-01 |
| Organization: | Illinois Dept Of Nuclear Safety |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+31.73 h1.322 days <br />0.189 weeks <br />0.0435 months <br />) | |
| Opened: | Joe Klinger 23:44 Aug 19, 2003 |
| NRC Officer: | John Mackinnon |
| Last Updated: | Aug 19, 2003 |
| 40088 - NRC Website | |
Rush North Medical Center with Agreement State | |
WEEKMONTHYEARENS 400882003-08-18T16:00:00018 August 2003 16:00:00
[Table view]Agreement State Patient Exceeded Prescribed Dose. 2003-08-18T16:00:00 | |