ENS 41932

v t e ENS Event
21:00 Aug 15, 2005
Title	Agreement State - Medical Event
Event Description	The State provided the following information via facsimile: The State received a telephone call from an RSO with The University of Texas Southwestern Medical Center (UTSWMC) at Dallas on August 16, 2005 at 4:00 p.m. to report a patient misadministration of a therapy dose at UTSWMC Moncrief Medical Center. The event occurred on August 15, 2005 around 4:00 pm. The patient was scheduled to receive 1100 centiGray in two fractions for cancer treatment. Each fraction was supposed to be 550 centiGray to the vaginal vault. The first dose was oriented interior 4 1/2 cm, i.e. too close. The true target point of the vaginal vault received a dose of 1451 centiGray. The second dose was not administered and the patient is not returning for further treatment. Source was an Ir-192 HDR (high dose rate) afterloader.

ENS 41932 +/-
Where
Univ Of Tx Sw Medical Center Dallas, Texas (NRC Region 4)
License number:	L00384-004
Organization:	Texas Department Of Health
Reporting

Agreement State
Time - Person (Reporting Time:+91.33 h3.805 days <br />0.544 weeks <br />0.125 months <br />)
Opened:	Latischa Hanson 16:20 Aug 19, 2005
NRC Officer:	Bill Huffman
Last Updated:	Aug 19, 2005
41932 - NRC Website
v • d • e

v t e Emergency Notification System
Univ Of Tx Sw Medical Center with Agreement State
WEEKMONTHYEAR2005-08-15T21:00:00 [Table view]
[ENS list for Univ Of Tx Sw Medical Center]

Navigation menu