ENS 44834

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v t e ENS Event
02:00 Feb 5, 2009
Title	Agreement State Report Involving a Dose Delivered to the Wrong Treatment Site
Event Description	The following information was received from the State of California via email: On February 5, 2009, [the Radiation Safety Officer (RSO) for the] City of Hope/Beckman Research Institute, contacted LA County Radiation Management regarding a misadministration that occurred at approximately 6:00 pm on February 4, 2009. The incident involved HDR treatment of the wrong site. Using HDR, a patient was scheduled for groin sarcoma therapy treatment. The treatment planning comprised of administration of approximately 4000 cGy to the tumor. The dose is to be administered in 10 fractions of 400 cGy/fraction; 2 fractions per day for 5 days. Six catheters to be administered/fraction. Per [the RSO], an error was made in the interpretation of the CT data, and therefore, the wrong distance was calculated. On February 4, 2009, the first day of the treatment, the catheters administered went to the body, past the tumor site, then to the outside of the thigh. [The RSO] stated that there was no dose administered to the tumor. All the dose was administered to the skin of the thigh. The patient had two treatments, and received approximately 800 cGy to the skin of the thigh. "A written report will be submitted by the licensee within 15 days. Based on the current report of 800 rad to the wrong treatment site (skin), this medical event does not meet the criteria for an Abnormal Occurrence (see SA-300, Appendix section 6.3.IV). CA 5010 Number: 020509 A Medical Event may indicate potential problems in a medical facilities use of radioactive materials. It does not necessarily result in harm to the patient.

ENS 44834 +/-
Where
City Of Hope/Beckman Research Institute Duate, California (NRC Region 4)
License number:	0307-19
Organization:	California Radiation Control Prgm
Reporting

Agreement State
Time - Person (Reporting Time:+35.43 h1.476 days <br />0.211 weeks <br />0.0485 months <br />)
Opened:	L. Robert Greger 13:26 Feb 6, 2009
NRC Officer:	Steve Sandin
Last Updated:	Feb 6, 2009
44834 - NRC Website
v • d • e

v t e Emergency Notification System
City Of Hope/Beckman Research Institute with Agreement State
WEEKMONTHYEAR2009-02-05T02:00:00 [Table view]
[ENS list for City Of Hope/Beckman Research Institute]

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ENS Notification