ENS 41905

v t e ENS Event
04:00 Jul 18, 2005
Title	Agreement State Report - Medical Event
Event Description	The State provided the following information via facsimile: Treatment delivered to two (2) of seven (7) lesions on a patient on 18 July 2005, were discovered to be 50 percent less dose than that prescribed. (15 Gy (Grey) per lesion prescribed; two lesions received only 7.5 Gy each) This was discovered [on 3 August 2005], during an internal audit of treatments, conducted by medical physicist not originally involved with treatment. To date the investigation does not identify a problem with the equipment or the dose programs involved in planning. Initial indicators point to a potential communication problem between the original medical physicist and oncologist. At this time the investigation is pending due to the unavailability of the medical physicist due to vacation. Resumption of the investigation is to commence on or about 9 August 2005 when persons involved have returned from vacation. RI Event Report ID: RI-05-003

ENS 41905 +/-
Where
Rhode Island Hospital Providence, Rhode Island (NRC Region 1)
License number:	7A-051-02
Organization:	Ri Dept Of Radiological Health
Reporting

Agreement State
Time - Person (Reporting Time:+539.95 h22.498 days <br />3.214 weeks <br />0.74 months <br />)
Opened:	Jack Ferruolo 15:57 Aug 9, 2005
NRC Officer:	Bill Gott
Last Updated:	Aug 9, 2005
41905 - NRC Website
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v t e Emergency Notification System
Rhode Island Hospital with Agreement State
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