ENS Event | |
|---|---|
21:00 Aug 15, 2005 | |
| Title | Agreement State Report |
| Event Description | The licensee provided the following information via email:
The written prescribed dose for this treatment was 550 cGy with the plan of repeating another procedure one week afterwards for a total prescribed dose of 1100 cGy. This dose, to be given in 2 fractions, was to be delivered to the vaginal cavity using High Dose Rate (HDR) afterloader device. The first fractionation of 550 cGy was delivered incorrectly, approximately 4.5 cm anterior to the correct position. This resulted in the intended target area receiving 1451 cGy in one treatment. The medical physicist discovered the error in the brachytherapy vision software (planning system). When digitizing the calculation point of the coronal plane, the sagittal plane viewing plane was in an incorrect position that resulted in the calculation point being entered incorrectly. There was no other medical physicist to second check the plan at that time due to personnel shortage issues. The prescribing physician determined that the clinical effect of the dose is negligible and there is no impact to the patient's well being. Texas Incident number: I-8253 Event Report ID No: TX-05-41932 |
| Where | |
|---|---|
| Ut Southwestern Medical Center Fort Worth, Texas (NRC Region 4) | |
| License number: | L00384-004 |
| Organization: | Texas Department Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+1772.83 h73.868 days <br />10.553 weeks <br />2.428 months <br />) | |
| Opened: | Latischa Hanson 17:50 Oct 28, 2005 |
| NRC Officer: | Bill Gott |
| Last Updated: | Oct 28, 2005 |
| 42091 - NRC Website | |
Ut Southwestern Medical Center with Agreement State | |
WEEKMONTHYEARENS 466172011-02-15T22:30:00015 February 2011 22:30:00
[Table view]Agreement State Agreement State Report - Possible Medical Event Due to Misadministration ENS 420912005-08-15T21:00:00015 August 2005 21:00:00 Agreement State Agreement State Report 2011-02-15T22:30:00 | |