ENS 48411

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v t e ENS Event
07:00 Oct 15, 2012
Title	Agreement State Report - Dose Different from Prescribed
Event Description	The following report was received from the Nevada Radiation Control Program via e-mail: We would just like to inform you of a medical event. Preliminary info: Yesterday (10-15-2012) we received a call from the RSO of 21st Century Oncology, regarding an incident that occurred with their HDR. Due to a faulty ruler, a parameter was entered incorrectly in the HDR control panel, resulting in a dose to the skin of the patient of around 160 centiGray. The skin area was one cubic cm. The intended dose was 160-170 cGy [to a different treatment site]. The intended target was an almost spherical volume located in the right breast. The skin that was exposed is located in the right breast, at the entrance of the device (multi lumen mammosite) catheter. The closest organ is the right lung. The patient is fine and was informed of this. The sealed source remained inside the tube. [The event is] being reported under 10 CFR 35.3045 (a)(3): A dose to the skin or an organ or tissue other than the treatment site that exceeds by 0.5 Sv (50 rem) to an organ or tissue and 50 percent or more of the dose expected from the administration defined in the written directive (excluding, for permanent implants, seeds that were implanted in the correct site but migrated outside the treatment site). 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 48411 +/-
Where
21St Century Oncology Las Vegas, Nevada (NRC Region 4)
Organization:	Nv Div Of Rad Health
Reporting

Agreement State
Time - Person (Reporting Time:+34.38 h1.433 days <br />0.205 weeks <br />0.0471 months <br />)
Opened:	Sneha Ravikumar 17:23 Oct 16, 2012
NRC Officer:	Bill Huffman
Last Updated:	Oct 16, 2012
48411 - NRC Website
v • d • e

v t e Emergency Notification System
21St Century Oncology with Agreement State
WEEKMONTHYEAR2015-08-27T05:00:00 [Table view]
[ENS list for 21St Century Oncology]

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