ENS 42721

v t e ENS Event
04:00 Jul 21, 2006
Title	Florida Agreement State Notification of Medical Event
Event Description	The State provided the following information via email: The RSO [Deleted] of Florida Hospital called. Florida Hospital in Ormond Beach (873 Sterthaus Ave, Ormond Beach, FL 32174) had a medical misadministration. They were using a HDR (Nucleotron Microselectron Classic, 8 Ci Ir-192 activity) to deliver vaginal treatment of 500 cGy per fraction. A typical patient gets 3-5 fractions. The delivery tube was 18.5 cm too long resulting in the source being outside the patient. The RSO indicated that the dose to the prescribed area was zero. [Due to the patients position, it was determined that] the dose to the skin is probably not too high. The Medical Physicist [MP] [deleted] has not yet determined what the skin dose estimate would be. [The MP] discovered the mistake after observing a treatment. The mistake happened because two different types of applicators are used. One has a longer tube than the other. The tubes were mixed up, which resulted in the misadministration. At least one patient is affected by this and maybe as many as 4 others. The MP believes that using film recorded for each treatment, the hospital can determine how many and which patients are affected. The treating physician has been notified, the referring physician and the patient have not. The State of Florida Bureau of Radiation Control will investigate.

ENS 42721 +/-
Where
Adventist Health System Altamonte Springs, Florida (NRC Region 1)
License number:	2897-1
Organization:	Florida Bureau Of Radiation Control
Reporting

Agreement State
Time - Person (Reporting Time:+14.52 h0.605 days <br />0.0864 weeks <br />0.0199 months <br />)
Opened:	John Williamson 18:31 Jul 21, 2006
NRC Officer:	Arlon Costa
Last Updated:	Jul 21, 2006
42721 - NRC Website
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