ENS Event | |
|---|---|
14:00 Dec 10, 2010 | |
| Title | Medical Event - Treatment Area Different from the Prescribed Area |
| Event Description | A High Dose Rate brachytherapy treatment with a 5.11 Ci source of Ir-192 was performed on a patient for vaginal cancer. The prescribed procedure was for a tube be inserted into the vaginal area for 120 cm, however, the treatment length of insertion was 132 cm. This was an out-patient procedure, so the patient went home after her treatment. The physician will be notifying the patient of the 12 cm insertion error.
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.
The brachytherapy exposure was received by four patients with the 12 cm insertion error. Three patients received three fractions each and the fourth received five fractions. The physicians have been notified except for the fourth patient's physician who will be notified. Notified the R3DO (Kazak) and FSME (O'Sullivan). |
| Where | |
|---|---|
| Henry Ford Macomb Clinton Township, Michigan (NRC Region 3) | |
| License number: | 21-11850-01 |
| Organization: | Henry Ford Macomb |
| Reporting | |
| 10 CFR 35.3045(a)(1) | |
| Time - Person (Reporting Time:+0.95 h0.0396 days <br />0.00565 weeks <br />0.0013 months <br />) | |
| Opened: | Brett Miller 14:57 Dec 10, 2010 |
| NRC Officer: | John Knoke |
| Last Updated: | Dec 15, 2010 |
| 46472 - NRC Website | |
Henry Ford Macomb with 10 CFR 35.3045(a)(1) | |
WEEKMONTHYEARENS 464722010-12-10T14:00:00010 December 2010 14:00:00
[Table view]10 CFR 35.3045(a)(1) Medical Event - Treatment Area Different from the Prescribed Area 2010-12-10T14:00:00 | |