ENS 41361

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v t e ENS Event
03:30 Jan 26, 2005
Title	Medical Event During Treatment for Cancer of the Cervix
Event Description	A patient undergoing a 31 hour3.587963e-4 days <br />0.00861 hours <br />5.125661e-5 weeks <br />1.17955e-5 months <br /> treatment plan for cervical cancer received less than the prescribed dose delivered to the treatment site and a higher than intended dose to other tissue(s)/organ(s), specifically: Treatment site A: planned 1643 centiGray, delivered 821 centiGray Treatment site B: planned 465 centiGray, delivered 372 centiGray Bladder: planned 1147 centiGray, delivered 1448 centiGray Rectum: planned 1147 centiGray, delivered 2012 centiGray Treatment was delivered from 1430 hours0.0166 days <br />0.397 hours <br />0.00236 weeks <br />5.44115e-4 months <br /> on 1/24 and 2130 hours0.0247 days <br />0.592 hours <br />0.00352 weeks <br />8.10465e-4 months <br /> on 1/25 using a low dose rate tandem brachytherapy device containing three Cs-137 sources; 14 milligram Ra-equiv, 9.8 milligram Ra-equiv and 9.8 milligram-equiv. There were two additional Cs-137 ovoid sources, each 14.1 milligram Ra-equiv. The tandem device has a rod that was cut 6 cm. short such that when the tandem was positioned in the patient, the three tandem sources were not extended the proper distance inside the tandem device. The ovoid sources were properly positioned. The referring physician and patient have been informed. The radiation staff oncologist does not believe that this medical event will have any adverse effect on the patient and a new treatment plan is being prepared for the patient.

ENS 41361 +/-
Where
University Of Minnesota Minneapolis, Minnesota (NRC Region 3)
License number:	22-00187-46
Organization:	University Of Minnesota
Reporting

10 CFR 35.3045(a)(1) 10 CFR 35.3045(a)(3)
Time - Person (Reporting Time:+33.5 h1.396 days <br />0.199 weeks <br />0.0459 months <br />)
Opened:	Jerry Staiger 13:00 Jan 27, 2005
NRC Officer:	Steve Sandin
Last Updated:	Jan 27, 2005
41361 - NRC Website
v • d • e

v t e Emergency Notification System
University Of Minnesota with 10 CFR 35.3045(a)(1), 10 CFR 35.3045(a)(3)
WEEKMONTHYEAR2005-01-26T03:30:00 [Table view]
[ENS list for University Of Minnesota]

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