ENS Event | |
|---|---|
15:00 Jul 24, 2007 | |
| Title | Medical Event - Administered Dose Less than Prescribed Dose |
| Event Description | The treatment consisted of 3 fractionated high dose rate (HDR) brachytherapy procedures. The dose was prescribed by the physician at 5 millimeters from the surface of the cylinder, however, the dose was calculated at the surface of the cylinder. The HDR brachytherapy was administered at 5 millimeters as prescribed. Due to the discrepancy between the prescribed and calculated dose an under dose of the patient of over 4 Grays (Gy) resulted. The prescription was for an administration of 15 Gy. Only 10.3 Gy was administered. The physician is planning to add one more fraction to complete the intended treatment of 15 Gy. The patient will be informed of this misadministration.
The licensee indicated that they will verify the prescription and the film prior to administration to insure consistency between the two. Additionally, when the dose distribution is plotted, the licensee will overlay the cylinder over the dose distribution to visually verify the dose. 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 | |
|---|---|
| Lester Cox Medical Center Springfield, Missouri (NRC Region 3) | |
| License number: | 24-01143-06 |
| Organization: | Lester Cox Medical Center |
| Reporting | |
| 10 CFR 35.3045(a)(1) | |
| Time - Person (Reporting Time:+-0.75 h-0.0313 days <br />-0.00446 weeks <br />-0.00103 months <br />) | |
| Opened: | John Pacyniak 14:15 Jul 24, 2007 |
| NRC Officer: | Jason Kozal |
| Last Updated: | Jul 24, 2007 |
| 43516 - NRC Website | |
Lester Cox Medical Center with 10 CFR 35.3045(a)(1) | |
WEEKMONTHYEARENS 435162007-07-24T15:00:00024 July 2007 15:00:00
[Table view]10 CFR 35.3045(a)(1) Medical Event - Administered Dose Less than Prescribed Dose 2007-07-24T15:00:00 | |