ENS 42774

v t e ENS Event
04:00 May 12, 2003
Title	Agreement State Report - Medical Event
Event Description	The State provided the following information regarding a previously unreported event via facsimile: The Agency [MA Radiation Control Program] received a report on 6/23/03 of a misadministration; ie., The wrong area of the scalp was treated during a treatment for a superficial scalp cancer. The wrong area of the scalp was treated because of a malfunction with the source position simulator. The misadministration was not noticed during the treatment period of May 12, 2003, thru June 5, 2003. It was discovered on June 23, 2003 while doing a similar procedure. After the source position simulator malfunction was detected, all cases that used this same device were reviewed and it was determined that only the last patient treatment was affected by this malfunction. Corrective actions were implemented to ensure this event will not happen again. Corrective action 1. Licensee reviewed all cases that involved the same device and determined that the only patient affected by this malfunction was the last one treated before discovery. 2. All HDR treatments involving variable length catheters will have the length of the catheters measured by 2 independent means. 3. The HDR manufacturer was notified of the problem encountered with the catheter measuring device.

ENS 42774 +/-
Where
Brigham & Women'S Hospital Boston, Massachusetts (NRC Region 1)
License number:	44-0004
Organization:	Ma Radiation Control Program
Reporting

Agreement State
Time - Person (Reporting Time:+28593.4 h1,191.392 days <br />170.199 weeks <br />39.167 months <br />)
Opened:	Mike Whalen 13:24 Aug 15, 2006
NRC Officer:	Bill Gott
Last Updated:	Aug 15, 2006
42774 - NRC Website
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v t e Emergency Notification System
Brigham & Women'S Hospital with Agreement State
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