ENS Event | |
|---|---|
07:00 Aug 9, 2006 | |
| Title | Agreement State - Medical Event |
| Event Description | The State provided the following information via email:
On August 11, 2006, RHB received notification from North Oaks Radiation Center of a potential medical event. On August 9, 2006, a patient was undergoing the third of three fractional doses from a Nucletron Model MicroSelectron-HDR Classic Afterloader, using Ir-192. The first two fractions had been delivered properly. When this fraction was delivered, the medical physicist inadvertently selected the wrong delivery tube. There are two delivery tubes available depending upon the treatment plan. In this case, the longer tube was incorrectly selected for this fraction, and the source remained outside the patient for the entire fraction. The preliminary estimate of the highest dose in this configuration was approximately 100 - 125 rads to the perineum, which was not the intended treatment site, and which would have received less than 50 rads with the intended configuration. The patient has been notified. The California Radiologic Health Branch will investigate this incident. |
| Where | |
|---|---|
| North Oaks Radiation Center Thousand Oaks, California (NRC Region 4) | |
| License number: | 3693-56 |
| Organization: | California Radiation Control Prgm |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+132.32 h5.513 days <br />0.788 weeks <br />0.181 months <br />) | |
| Opened: | Barbara Hamrick 19:19 Aug 14, 2006 |
| NRC Officer: | Jeff Rotton |
| Last Updated: | Aug 14, 2006 |
| 42768 - NRC Website | |
North Oaks Radiation Center with Agreement State | |
WEEKMONTHYEARENS 427682006-08-09T07:00:0009 August 2006 07:00:00
[Table view]Agreement State Agreement State - Medical Event 2006-08-09T07:00:00 | |