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
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. |
| 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 | |
California Surgery Center with Agreement State | |
WEEKMONTHYEARENS 432582007-03-19T07:00:00019 March 2007 07:00:00
[Table view]Agreement State Agreement State - California - Medical Misadministration 2007-03-19T07:00:00 | |