ENS 41666

v t e ENS Event
22:20 May 2, 2005
Title	Medical Event: Brachytherapy Under Dose Administration
Event Description	On May 2, 2005 to May 3, 2005 during a planned 1 day 5 hour5.787037e-5 days <br />0.00139 hours <br />8.267196e-6 weeks <br />1.9025e-6 months <br /> 22 minute brachytherapy vaginal dose a calculated 27% under dose of 1825 cGy dose was administered in a 2.5 cm solid vaginal cylinder. Two 19.56 mg Ra equivalent Cs-137 sources were used. This event was discovered on May 4, 2005 at 10 am, during a summary review, when the licensee discovered that the wrong size applicator cylinder was used. A 1.93 cm cylinder was planned to have been used to apply a 2500 cGy total dose. The licensee contacted the patient about the under dose and plans to administer the rest of the dose on May 5, 2005. The licensee is formulating a plan to administer additional training to the hospital staff to prevent future events of this type.

ENS 41666 +/-
Where
Union Hospital Terre Haute, Indiana (NRC Region 3)
License number:	13-16457-01
Organization:	Union Hospital
Reporting

10 CFR 35.3045(a)(1)
Time - Person (Reporting Time:+64.08 h2.67 days <br />0.381 weeks <br />0.0878 months <br />)
Opened:	Gary Adler 14:25 May 5, 2005
NRC Officer:	Pete Snyder
Last Updated:	May 5, 2005
41666 - NRC Website
v • d • e

v t e Emergency Notification System
Union Hospital with 10 CFR 35.3045(a)(1)
WEEKMONTHYEAR2005-05-02T22:20:00 [Table view]
[ENS list for Union Hospital]

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