ENS 42511

v t e ENS Event
15:40 Apr 11, 2006
Title	Medical Event - Administration of Greater than 50 Percent of Prescribed Dose to Patients
Event Description	The RSO of the United Hospital Center called about a misadministration to 2 female patients being treated for cervical cancer. Each patient was to receive a total of 3000 centigrays, distributed via 6 treatments of 500 centigrays each. The treatment was a high dose rate Brachytherapy insertion of a 4.4 Curie Ir-192 sealed source into the cervical area. On their first treatment, patient #1 received 1040 centigrays at 11:40 EDT on 04/11/06, and patient #2 received 1058 centigrays at 11:45 EDT on 4/18/06. The attending physician is now going to alter the remaining treatments to 350 centigrays/treatment for each patient, thereby keeping the original total dose to the required 3000 centigrays/patient. The reason given for the misadministration was human error. The operator did not check the magnification reading on the computer before administrating the dose to each patient. The referring physician will be discussing this error with each patient when they come in for their next treatment on 4/21/06.

ENS 42511 +/-
Where
United Hospital Center Clarksburg, West Virginia (NRC Region 1)
License number:	4701458-01
Organization:	United Hospital Center
Reporting

10 CFR 35.3045(a)(3)
Time - Person (Reporting Time:+190.55 h7.94 days <br />1.134 weeks <br />0.261 months <br />)
Opened:	James Israel - Rso 14:13 Apr 19, 2006
NRC Officer:	John Knoke
Last Updated:	Apr 19, 2006
42511 - NRC Website
v • d • e

v t e Emergency Notification System
United Hospital Center with 10 CFR 35.3045(a)(3)
WEEKMONTHYEAR2006-04-11T15:40:00 [Table view]
[ENS list for United Hospital Center]

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