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. |
| 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 | |
Union Hospital with 10 CFR 35.3045(a)(1) | |
WEEKMONTHYEARENS 416662005-05-02T22:20:0002 May 2005 22:20:00
[Table view]10 CFR 35.3045(a)(1) Medical Event: Brachytherapy Under Dose Administration 2005-05-02T22:20:00 | |