ENS 40611

v t e ENS Event
13:45 Mar 25, 2004
Title	Agreement State Report Involving a Misadminstration During Eye Treatment
Event Description	Event description: A pterygium patient was scheduled to receive a 42.5 second treatment utilizing a 100 millicurie Srontium-90 sealed source manufactured by 3M Company, model number 6D1A. The dosimetrist programmed the manual timer for 4 minutes and 25 seconds. During the treatment, the physician questioned the treatment time and it was terminated after 2 minutes and 30 seconds. The prescribed dose was 20 Gy. The patient received 70.59 Gy. The patient and the physician were notified of the misadministration. The licensee notified the Division the same day of the event. The licensee will submit a written report within 15 days. This incident is reportable under 1200-2-5-.32 (79) (e) (4) of 'State Regulations for Protection Against Radiation.' TN Event Report ID No.: TN-04-035

ENS 40611 +/-
Where
Saint Francis Hospital Memphis, Tennessee (NRC Region 1)
License number:	R-79104
Organization:	Tennessee Div Of Rad Health
Reporting

Agreement State
Time - Person (Reporting Time:+25.13 h1.047 days <br />0.15 weeks <br />0.0344 months <br />)
Opened:	Debra Shults 14:53 Mar 26, 2004
NRC Officer:	Steve Sandin
Last Updated:	Mar 26, 2004
40611 - NRC Website
v • d • e

v t e Emergency Notification System
Saint Francis Hospital with Agreement State
WEEKMONTHYEAR2004-03-25T13:45:00 [Table view]
[ENS list for Saint Francis Hospital]

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