ENS 43258

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v t e ENS Event
07:00 Mar 19, 2007
Title	Agreement State - California - Medical Misadministration
Event Description	The State provided the following information via facsimile: On March 16, 2007, the licensee initiated a 'Mammosite' treatment of a patient, with a total prescribed dose of 3400 cGy (3400 rad) to be delivered in 10 fractions of 340 cGy (340 rad) each, over the course of 5 days, using a Nucletron, Model 105.999 HDRA with 4.1 Ci Ir-192 (as of the first day of treatment). The first five fractions were delivered uneventfully. During the last five fractions, the radiation therapy technologist accidentally imported the wrong treatment plan, resulting in an underdose to the treatment area. The dwell position of the source was actually fully outside of the patient, so the tumor received effectively no dose. The licensee is calculating the skin and whole body dose to the patient, but currently estimates it will not have an adverse affect upon the patient. The patient and referring physician have been notified, and re-treatment has been scheduled to begin tomorrow. This event was discovered upon review of the patient's chart when the patient returned for a follow-up exam. The licensee will provide a written report of the event within 15 days." CA Report #032707 * * UPDATED 1346 EDT ON 4/2/07 FROM CYNTHIA FLANNERY (FSME) * * * This event has been reviewed by FSME and found to be a medical event. 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 43258 +/-
Where
California Surgery Center Bakersfield, California (NRC Region 4)
License number:	6833-15
Organization:	California Radiation Control Prgm
Reporting

Agreement State
Time - Person (Reporting Time:+202.87 h8.453 days <br />1.208 weeks <br />0.278 months <br />)
Opened:	Barbara Hamrick 17:52 Mar 27, 2007
NRC Officer:	Bill Huffman
Last Updated:	Apr 2, 2007
43258 - NRC Website
v • d • e

v t e Emergency Notification System
California Surgery Center with Agreement State
WEEKMONTHYEAR2007-03-19T07:00:00 [Table view]
[ENS list for California Surgery Center]

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