ENS 44578

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v t e ENS Event
04:00 Sep 17, 2008
Title	Agreement State Report - Dose to Unintended Tissues
Event Description	The Commonwealth of Florida was notified on 10/17/2008 by the licensee's Medical Physicist regarding a dose of 3400 cGy (3400 rad) administered to unintended tissues during several breast cancer therapy treatments over the period of September 10 - 17, 2008. The apparent unintended dose was identified on 10/16/2008, when the patient reported to the licensee symptoms of erythma (skin reddening) to the breast not intended to be treated. Specifically, the patient was being treated for breast cancer with an Ir-192 High Dose Rate (HDR) Afterloader unit (source strength, manufacturer, and model unknown at the time of this report). When the erythema was reported by the patient, the Medical Physicist reviewed the records and determined that the HDR Afterloader was mis-programmed such that the source stopped 10 centimeters short of the intended tumor bed in the right breast. As a result, the entire dose intended for the tumor bed was administered to the left breast that was not intended to be treated. The Commonwealth of Florida did not currently have information regarding any potential long term effects for the patient due to this event. The Commonwealth of Florida will dispatch an inspector to the facility early next week to follow-up on this event. A written report of this event will be provide by the State at that time. 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 44578 +/-
Where
St. Vincent'S Hospital Jacksonville, Florida (NRC Region 1)
License number:	FL Lic 14-6
Organization:	Florida Bureau Of Radiation Control
Reporting

Agreement State
Time - Person (Reporting Time:+733.8 h30.575 days <br />4.368 weeks <br />1.005 months <br />)
Opened:	David Ferguson 17:48 Oct 17, 2008
NRC Officer:	Ryan Alexander
Last Updated:	Oct 17, 2008
44578 - NRC Website
v • d • e

v t e Emergency Notification System
St. Vincent'S Hospital with Agreement State
WEEKMONTHYEAR2008-09-17T04:00:00 [Table view]
[ENS list for St. Vincent'S Hospital]

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