ENS 41925

v t e ENS Event
18:30 Aug 4, 2005
Title	Agreement State Report - Medical Event
Event Description	The State provided the following information via facsimile: This event involved an HDR brachytherapy unit [Nucletron Corporation Model 105.999, serial number 31062; with sealed source Nucletron Corporation Model 105.002, serial number D36A-7277]. The maximum activity that can be utilized in the unit is 444 gigabecquerels (12 Curies) of Ir-192. The male patient was receiving palliative treatment for metastatic disease. On August 4, 2005, the patient received the second of the three prescribed treatments to the left bronchus. The licensee's Medical Physicist discovered the error on August 10, 2005. The error was a contiguous shift lengthwise of 3 centimeters from the area that was being treated. The intended fraction was 7 Gray. The patient and the referring physician were notified on August 11, 2005. The licensee is still in the process of evaluating the event. The licensee is to submit a written report to the Utah Division of Radiation Control. The treating physician determined that there will be no adverse affect to the patient as a result of this event and that diseased tissue may have been treated. The Division of Radiation Control is still investigating this event. Event Report ID Number: UT-05-0006

ENS 41925 +/-
Where
University of Utah Salt Lake City, Utah (NRC Region 4)
License number:	UT 1800001
Organization:	Utah Division Of Radiation Control
Reporting

Agreement State
Time - Person (Reporting Time:+312.45 h13.019 days <br />1.86 weeks <br />0.428 months <br />)
Opened:	Julie Felice 18:57 Aug 17, 2005
NRC Officer:	Bill Gott
Last Updated:	Aug 17, 2005
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