ENS 46412

v t e ENS Event
17:00 Nov 10, 2010
Title	Agreement State Report - Underdosage to Intended Treatment Area
Event Description	The following was received via e-mail: At approximately 11:00 am on November 10, 2010, the Minnesota Department of Health was notified of a medical event that occurred at Mayo Clinic. Mayo Clinic reports during a biliary LDR treatment using Iridium-192, the catheter and guide wire moved and the radioactive sources moved out of position approximately 7 cm distal to the treatment location (still in the bile duct). The oncologist noticed the guide wire had moved at approximately 10:30 am on November 10, 2010, at that point the RSO was notified. It was determined that the intended treatment site received only 1.24 Gy of the intended dose of 20.0 Gy, making this a reportable event. MDH will continue to investigate and will do an on-site visit during the week of November 15. More information to follow. 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 46412 +/-
Where
Mayo Clinic Rochester, Minnesota (NRC Region 3)
License number:	1047-206-55
Organization:	Minnesota Department Of Health
Reporting

Agreement State
Time - Person (Reporting Time:+1.03 h0.0429 days <br />0.00613 weeks <br />0.00141 months <br />)
Opened:	Sherrie Flaherty 18:02 Nov 10, 2010
NRC Officer:	Joe O'Hara
Last Updated:	Nov 10, 2010
46412 - NRC Website
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