ENS Event | |
|---|---|
21:00 Feb 7, 2011 | |
| Title | Medical Events - Actual Dose Less than Prescribed Dose |
| Event Description | Nine breast cancer patients were treated with a multi-channel high dose rate afterloader with the incorrect dwell positions input into the afterloader controller. The intended prescription was for 5 mm between dwell positions. The actual input was 2.5 mm between dwell positions. The prescribed dose was for 3400 cGy and the actual dose delivered was approximately 25% less. No adverse clinical effects are expected.
The doctors and patients will be notified.
There were a total of eleven breast cancer patients involved. Seven of the eleven patients had small areas of unintended target that received unplanned dose. The doctors and patients have been notified. Notified R3DO (Riemer) and FSME (McIntosh) 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 | |
|---|---|
| Crittenton Hospital Medical Center Rochester, Michigan (NRC Region 3) | |
| License number: | 21-13562-01 |
| Organization: | Crittenton Hospital Medical Center |
| Reporting | |
| 10 CFR 35.3045(a)(1) | |
| Time - Person (Reporting Time:+15.08 h0.628 days <br />0.0898 weeks <br />0.0207 months <br />) | |
| Opened: | V. Arterbery 12:05 Feb 8, 2011 |
| NRC Officer: | Mark Abramovitz |
| Last Updated: | Mar 7, 2011 |
| 46601 - NRC Website | |
Crittenton Hospital Medical Center with 10 CFR 35.3045(a)(1) | |
WEEKMONTHYEARENS 516482016-01-11T05:00:00011 January 2016 05:00:00
[Table view]10 CFR 35.3045(a)(1) Medical Event - Patient Received Dose Greater than Prescribed ENS 466012011-02-07T21:00:0007 February 2011 21:00:00 10 CFR 35.3045(a)(1) Medical Events - Actual Dose Less than Prescribed Dose 2016-01-11T05:00:00 | |