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. |
| 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 | |
Sand Lake Cancer Center, P.A. with Agreement State | |
WEEKMONTHYEARENS 481962012-08-02T04:00:0002 August 2012 04:00:00
[Table view]Agreement State Patient Receives Under Dose 2012-08-02T04:00:00 | |