ENS 48903

v t e ENS Event
14:30 Apr 8, 2013
Title	Medical Event Involving a Mis-Positioned Brachytherapy Source
Event Description	On 04/08/13 at approximately 1030 EDT a female patient undergoing brachytherapy treatment for cervical/vaginal cancer received the first of three fractions. The prescribed dose for the first fraction was 400 cGy, however, the wrong length catheter was used. This placed the source 5 cm inferior to the intended treatment site. The actual dose received has not been determined at this time. This error was discovered on 04/09/13 during a review by the Medical Physicist. Both the prescribing physician and patient have been informed. There are no adverse health consequences anticipated due to this error in treatment. 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 48903 +/-
Where
Mid Michigan Medical Center Saginaw, Michigan (NRC Region 3)
License number:	21-01549-02
Organization:	Saginaw Radiation Oncology Center
Reporting

10 CFR 35.3045(a)(3)
Time - Person (Reporting Time:+24.43 h1.018 days <br />0.145 weeks <br />0.0335 months <br />)
Opened:	Ian Reineck 14:56 Apr 9, 2013
NRC Officer:	Steve Sandin
Last Updated:	Apr 9, 2013
48903 - NRC Website
v • d • e

v t e Emergency Notification System
Mid Michigan Medical Center with 10 CFR 35.3045(a)(3)
WEEKMONTHYEAR2013-04-08T14:30:00 [Table view]
[ENS list for Mid Michigan Medical Center]

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