ENS 46602

v t e ENS Event
05:00 Feb 8, 2011
Title	Agreement State Report - Under Dose Received During Brachytherapy Procedure
Event Description	The following information was received from the State of North Carolina via email: A patient undergoing a HDR [High Dose Rate] brachytherapy procedure received an under dose on three fractions. The guide tubes were misaligned which resulted in a 5 cm displacement from the source plan. This misalignment resulted in a 59% difference in dose (under dose) to the intended site and an overexposure to other tissue. The patient has received three of ten exposures and the plan will be re-worked to mitigate the under dosage of the intended site. The patient has been notified and they are trying to contact the prescribing physician to notify him. An investigation has been initiated to determine the cause of this event and corrective actions. 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 46602 +/-
Where
Rex Hospital Raleigh, North Carolina (NRC Region 1)
License number:	092-0160-1
Organization:	Nc Div Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+8.85 h0.369 days <br />0.0527 weeks <br />0.0121 months <br />)
Opened:	Henry Barnes 13:51 Feb 8, 2011
NRC Officer:	John Shoemaker
Last Updated:	Feb 8, 2011
46602 - NRC Website
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v t e Emergency Notification System
Rex Hospital with Agreement State
WEEKMONTHYEAR2011-02-08T05:00:00 [Table view]
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