ENS 48196

v t e ENS Event
04:00 Aug 2, 2012
Title	Patient Receives Under Dose
Event Description	The following report was received via fax. Received report from the RSO on 2 Aug 2012 at approximately 1430 [EDT] hrs of a medical event that occurred on 1 Aug 2012. Two patients with similar procedures (mammosite) were being treated with an HDR [High Dose Rate]. First patient correctly treated, second patient treated with the same plan as the first. Second patient only under dosed by 0.5%. Their treatment plans were allegedly the same. Orlando office investigated licensee and found violation to be caused by operator error. Corrective action consists of a 'Time Out' to verify patient's name, plan, and treatment settings. Further action referred to the Office of Licensing and Materials, this office will take no further action on this incident. The device is a Nucletron Microselection HDR; S/N 31591. Florida Incident: FL12-061. 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 48196 +/-
Where
Sand Lake Cancer Center, P.A. Orlando, Florida (NRC Region 1)
License number:	4162-2
Organization:	Florida Bureau Of Radiation Control
Reporting

Agreement State
Time - Person (Reporting Time:+347.03 h14.46 days <br />2.066 weeks <br />0.475 months <br />)
Opened:	Steve Furnace 15:02 Aug 16, 2012
NRC Officer:	John Shoemaker
Last Updated:	Aug 16, 2012
48196 - NRC Website
v • d • e

v t e Emergency Notification System
Sand Lake Cancer Center, P.A. with Agreement State
WEEKMONTHYEAR2012-08-02T04:00:00 [Table view]
[ENS list for Sand Lake Cancer Center, P.A.]

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