ENS 42091

v t e 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

ENS 42091 +/-
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
v • d • e

v t e Emergency Notification System
Ut Southwestern Medical Center with Agreement State
WEEKMONTHYEAR2011-02-15T22:30:00 [Table view]
[ENS list for Ut Southwestern Medical Center]

Navigation menu