ENS Event | |
|---|---|
05:00 Feb 1, 2005 | |
| Title | Agreement State Report - Dose Differs by Greater than 50% of Prescribed |
| Event Description | The State provided the following information via email:
A teletherapy patient received a dose greater than 50% of the prescribed fractionated dose due to an improperly calculated dose delivery time. The medical physicist used a fractionated dose of 200 cGy instead of the prescribed dose of 100 cGy. This overexposure occurred during the first fraction to the patient. Before the second scheduled treatment, a different therapist questioned the long treatment time and brought the matter to the medical physicist. The physicist checked the calculations, discovered the error and cancelled the treatment for the day. The radiation oncologist anticipates no unusual acute or late effects from the delivered dose. The University of Iowa no longer is in possession of this device. It was de-sourced on November 16, 2005. The device was a sealed Co-60 teletherapy source. The therapy was targeting the bone marrow. Iowa report number: IA070003 |
| Where | |
|---|---|
| University of Iowa Iowa City, Iowa (NRC Region 3) | |
| License number: | 0037152AAB |
| Organization: | Iowa Department Of Public Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+22907.07 h954.461 days <br />136.352 weeks <br />31.378 months <br />) | |
| Opened: | Randal Dahlin 15:04 Sep 13, 2007 |
| NRC Officer: | Jason Kozal |
| Last Updated: | Sep 13, 2007 |
| 43639 - NRC Website
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University of Iowa with Agreement State | |
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