ENS 40987

v t e ENS Event
05:00 Apr 20, 2004
Title	Agreement State Report - Incorrect Medical Treatment Site
Event Description	The following information was received via facsimile: The incident occurred on April 20, 2004 at the Tulane Cancer Center. The patient was being treated for cervical cancer. The Nucletron Source Position Simulator had previously been repaired by the service technician by providing a replacement screw. During measurement of correct catheter position with the device, the simulator cable became stuck resulting in underestimation of the required distance. This erroneous number was entered into the Nucletron HDR unit. The 9050 milliCurie source of Ir-192 did not extend to the desired location but remained outside the patient for approximately 2 minutes at 2.6 centimeters from the skin. The dose estimate for this was 270 R. The patient was notified and the treatment plan modified. As of July 21, 2004 there is no effect on the patient. To prevent reoccurrence the procedure was modified to test for looseness in the Source Position Simulator prior to use. Louisiana Report # LA040007

ENS 40987 +/-
Where
Tulane University New Orleans, Louisiana (NRC Region 4)
License number:	LA-0004-L01
Organization:	Louisiana Radiation Protection Div
Reporting

Agreement State
Time - Person (Reporting Time:+3082.33 h128.43 days <br />18.347 weeks <br />4.222 months <br />)
Opened:	Scott Blackwell 15:20 Aug 26, 2004
NRC Officer:	Mike Ripley
Last Updated:	Aug 26, 2004
40987 - NRC Website
v • d • e

v t e Emergency Notification System
Tulane University with Agreement State
WEEKMONTHYEAR2005-01-26T06:00:00 [Table view]
[ENS list for Tulane University]

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