ENS 45502

v t e ENS Event
05:00 Oct 26, 2009
Title	Agreement State Report - Medical Event
Event Description	The following report was received via facsimile: Patient liver is being treated by thera sphere procedure. First dose was intended to be for left lobe but was delivered to right lobe on 10/26/09. The second treatment was going to be for the right lobe. The window for the right lobe dose was90-115 grays, but what actually delivered was 18-51 % low. Error was discovered 10/30/09. The patient will be retreated to bring dose up to required level. The patient and doctor have been notified. In the future the radiologist will submit a written statement on the treatment to be preformed before it is accomplished. Licensee will submit a written report. No further action will be taken on this incident. Source: 1.27 GBq Y-90 Florida Incident: FL09-077 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 45502 +/-
Where
Boca Raton Community Hospital Boca Raton, Florida (NRC Region 1)
License number:	0550-1
Organization:	Florida Bureau Of Radiation Control
Reporting

Agreement State
Time - Person (Reporting Time:+535.83 h22.326 days <br />3.189 weeks <br />0.734 months <br />)
Opened:	Steve Furnace 13:50 Nov 17, 2009
NRC Officer:	Mark Abramovitz
Last Updated:	Nov 17, 2009
45502 - NRC Website
v • d • e

v t e Emergency Notification System
Boca Raton Community Hospital with Agreement State
WEEKMONTHYEAR2009-10-26T05:00:00 [Table view]
[ENS list for Boca Raton Community Hospital]

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