ENS 49102

v t e ENS Event
05:00 Aug 22, 2012
Title	Agreement State Report - Potential Medical Overdose
Event Description	The following report was received via e-mail: On May 26, 2013 during a transfer of electronic treatment planning records to a new system, the University of Minnesota (license number 1049-211-27) discovered a medical event that occurred on August 20-22, 2012 at the university of Minnesota Medical Center in Minneapolis with the Nucletron HDR. The licensee reported that dosimetry staff were testing the transfer of information from previously treated patients into a brachytherapy check program, and it was discovered that in this particular case the source position data was entered into the HDR planning system incorrectly. The licensee is calculating the exact doses delivered and it appears as though the dose to unintended regions by greater than 50% for several areas. The Minnesota Department of Health was notified of the potential event on May 27, 2013. A final report will be submitted when the report is received from the licensee. 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 49102 +/-
Where
University Of Minnesota Minneapolis, Minnesota (NRC Region 3)
License number:	1049-211-27
Organization:	Minnesota Department Of Health
Reporting

Agreement State
Time - Person (Reporting Time:+7019.88 h292.495 days <br />41.785 weeks <br />9.616 months <br />)
Opened:	Sherrie Flaherty 16:53 Jun 10, 2013
NRC Officer:	Mark Abramovitz
Last Updated:	Jun 10, 2013
49102 - NRC Website
v • d • e

v t e Emergency Notification System
University Of Minnesota with Agreement State
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