ENS 42556

v t e ENS Event
04:00 Mar 31, 2006
Title	Agreement State Report - Medical Event
Event Description	An 80 year old white female undergoing a Mammosite Brachytherapy (Nuclear Tron V2 model 31662) procedure utilizing Ir-192 source received less than 30% of the prescribed dose of 3400 centi-gray (cGy) (accumulated dose). An incorrect figure was entered into the computer causing the source to stay back 6 cm from the intended position and hence dosing an unintended area of approximately 2 cm with 3 times the prescribed dose of 10,000 cGy. The treatment was given 2 times a day for five days from March 31 to April 7, 2006. The patient saw the attending physician for follow-up on May 2, 2006. The physician discovered the patients skin abnormally red. He contacted the Medical Physicist who investigated and discovered the input error. The physician, patient and the patients family were notified. The patient is well and is being treated for erythema. Florida Incident number: FL 06-062

ENS 42556 +/-
Where
21St Century Oncology Coral Springs, Florida (NRC Region 1)
License number:	2667-1
Organization:	Florida Bureau Of Radiation Control
Reporting

Agreement State
Time - Person (Reporting Time:+850.82 h35.451 days <br />5.064 weeks <br />1.165 months <br />)
Opened:	Mark Seidenstricker 13:49 May 5, 2006
NRC Officer:	Bill Gott
Last Updated:	May 5, 2006
42556 - NRC Website
v • d • e

v t e Emergency Notification System
21St Century Oncology with Agreement State
WEEKMONTHYEAR2015-08-27T05:00:00 [Table view]
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