ENS Event | |
|---|---|
04:00 Oct 6, 2010 | |
| Title | Delivered Dose Potentially Different than the Prescribed Dose |
| Event Description | During a brachytherapy treatment, the patient breast received an incorrect entry of the catheter position from a treatment planning system. Because of this, the prescribed dose was 340 centi-Gray at 1 centimeter from the tumor cavity while the actual dose received was 680 centi-Gray at 1 centimeter from the tumor cavity.
The physician notified the patient of the potential dose difference. Based on physician review, it was determined that there was no affect on the patient. The reason for the potential dose difference was due to a missed change of a program default in the software program of the radiation treatment planning system. A new check step has been added to the Community Hospital procedure in order to correct the issue.
The licensee is updating this report to confirm that upon further evaluation this is a medical event. Notified R3DO (Skokowski) and FSME (Burgess). 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. |
| Where | |
|---|---|
| Community Hospital Indianapolis, Indiana (NRC Region 3) | |
| License number: | 130600901 |
| Organization: | Community Hospital |
| Reporting | |
| 10 CFR 35.3045(a)(1) | |
| Time - Person (Reporting Time:+53.95 h2.248 days <br />0.321 weeks <br />0.0739 months <br />) | |
| Opened: | Andrea Browne 09:57 Oct 8, 2010 |
| NRC Officer: | Vince Klco |
| Last Updated: | Oct 26, 2010 |
| 46319 - NRC Website | |
Community Hospital with 10 CFR 35.3045(a)(1) | |
WEEKMONTHYEARENS 463662010-10-26T04:00:00026 October 2010 04:00:00
[Table view]10 CFR 35.3045(a)(1) Two Medical Events Involving Received Dose Less than Prescribed Dose ENS 463192010-10-06T04:00:0006 October 2010 04:00:00 10 CFR 35.3045(a)(1) Delivered Dose Potentially Different than the Prescribed Dose ENS 463812008-05-28T04:00:00028 May 2008 04:00:00 10 CFR 35.3045(a)(1) Two Medical Events Involving Received Dose Less than Prescribed Dose 2010-10-06T04:00:00 | |