ENS 43960

v t e ENS Event
08:00 Jan 31, 2008
Title	Agreement State Report - Medical Event Radiation Treatment Not Administered Per Intention
Event Description	The following report was made by e-mail: In Radiation Oncology, a treatment was ordered for an HDR cylinder gynecological treatment of 2 fractions of 600 cGy to 5 mm past the surface of the cylinder. The treatment form was most likely filled out by a resident and was signed by both the resident and the attending radiation oncologist as stated by Environmental Health & Safety staff. When the radiation oncologist typed the official written directive into the IMPAC system, (Information for Management, Planning, Analysis and Coordination System), her intention was to treat 2 fractions of 600 cGy to the surface of the cylinder. The treatment was planned according to the written form to 5 mm past the surface of the cylinder. This plan was checked and signed off by the treating physician and was the treatment given to the patient. The radiation oncologist states that there should be no medical impact to the patient, as prescription to 5 mm past the surface of the cylinder is also an acceptable and standard treatment. The radiation oncologist has changed the prescription in IMPAC to reflect the dose that was given. The treating physician has notified both the referring physician and the patient. A 'medical event' indicates potential problems in a medical facility's use of radioactive materials. It does not result in harm to the patient.

ENS 43960 +/-
Where
U C Davis Medical Center Sacramento, California (NRC Region 4)
License number:	1334-34
Organization:	California Radiation Control Prgm
Reporting

Agreement State
Time - Person (Reporting Time:+104.05 h4.335 days <br />0.619 weeks <br />0.143 months <br />)
Opened:	Ken Furey 16:03 Feb 4, 2008
NRC Officer:	Karl Diederich
Last Updated:	Feb 4, 2008
43960 - NRC Website
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v t e Emergency Notification System
U C Davis Medical Center with Agreement State
WEEKMONTHYEAR2008-01-31T08:00:00 [Table view]
[ENS list for U C Davis Medical Center]

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