ENS 43220

v t e ENS Event
07:00 Mar 7, 2007
Title	Agreement State Report- Medical Event - Underdose to Patient
Event Description	During a series of fractional medical treatments given to the patient on 2/13/07 through 2/20/07, a dose of 24000 centigray was administered to the dose area of the patient instead of the 31092 centigray prescribed dose. The isotope used was Iridium-192. The source strength was unknown at the time of the report. The HDR misadministration was the result of a failure to correct for the proper length of the type of connector used in the procedure. The error resulted in a dose more than 20% below the prescribed dose. The error in the procedure was identified during the review process following the conclusion of the last dose fraction. The length of the connector differed from the correct length by 1.4 centimeters. The prescribing physician said that the patient will likely have a skin reaction to the treatment that will heal with time. The [Colorado Health] Department's inspector is scheduled to conduct an inspection at the Penrose Hospital on Monday, March 12, 2007. He was briefed with the known details of the misadministration at this date and will look further into this matter. The state expects to provide additional information at a later date. A "Medical Event" may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.

ENS 43220 +/-
Where
Centura Health: Penrose- St. Frances Health Services Colorado Springs, Colorado (NRC Region 4)
License number:	197-02
Organization:	Colorado Dept Of Health
Reporting

Agreement State
Time - Person (Reporting Time:+11.58 h0.483 days <br />0.0689 weeks <br />0.0159 months <br />)
Opened:	Thomas Pentecost 18:35 Mar 7, 2007
NRC Officer:	Pete Snyder
Last Updated:	Feb 27, 2007
43220 - NRC Website
v • d • e

v t e Emergency Notification System
Centura Health: Penrose- St. Frances Health Services with Agreement State
WEEKMONTHYEAR2007-03-07T07:00:00 [Table view]
[ENS list for Centura Health: Penrose- St. Frances Health Services]

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