ENS 43252

v t e ENS Event
04:00 Mar 5, 2007
Title	Agreement State - Medical Event Related to Dose Less than 20% Prescribed
Event Description	Upon quality review a misadministration was discovered by hospital staff on March 3, 2007; the actual medical procedure was performed on January 23, 2007. It is estimated that patient was administered a dose less than 20% of the intended dose. State was notified on 19 March 2007. This incident is referred to [the State's] radioactive materials [office] for investigation. The misadministration involved a Gamma Knife. A quality review by the licensee confirmed that a treatment dose was prescribed as - 40% of maximum dose equivalent equals 11Gy; but was calculated as - 50% of maximum dose equals 11Gy. This discrepancy resulted in the administration of a dose that was 20% less than intended. State Report FL07-046 * * Update on 03/20/07 at 1408 EDT via e-mail from FSME (C. Flannery) to MacKinnon * * * This event has been reviewed and determined to be a medical event. Immediate release to the public is authorized. 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 43252 +/-
Where
Doctors Hospital, Inc Coral Gables, Florida (NRC Region 1)
License number:	3823-2
Organization:	Florida Bureau Of Radiation Control
Reporting

Agreement State
Time - Person (Reporting Time:+367.95 h15.331 days <br />2.19 weeks <br />0.504 months <br />)
Opened:	Steve Furnace 10:57 Mar 20, 2007
NRC Officer:	Jeff Rotton
Last Updated:	Mar 20, 2007
43252 - NRC Website
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v t e Emergency Notification System
Doctors Hospital, Inc with Agreement State
WEEKMONTHYEAR2007-03-05T04:00:00 [Table view]
[ENS list for Doctors Hospital, Inc]

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