ENS 49331

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v t e ENS Event
05:00 Sep 6, 2013
Title	Agreement State Report - Dose Delivered to Wrong Site
Event Description	The following information was received from the State of Minnesota via email: The planned/prescribed dose that was to be delivered to a patient's tumor volume was 400cGy (4Gy) on this fraction. Due to medical event, [approximately] 0cGy (0Gy) was delivered to the tumor volume during HDR treatment fraction #2 of 6. The prescribed fraction dose of 400cGy (4Gy) was unintentionally delivered 5.4cm superiorly to the tumor volume in the patient's small bowel/external bladder wall region. The HDR remote afterloader at Abbott-Northwestern being used/in use during this patient's treatment is a Nucletron/Elekta V2 mHDR, serial number 31823; mHDR Ir-192 source #D36E-6829. The Ir-192 source activity at time of above medical event was 6.407 Ci. Abbott-Northwestern Radiation Oncology is actively investigating the cause of the above medical event, corrective action(s) to implement to prevent such an event from happening in the future, and any medical follow-up/expected implications to the patient from the above medical event. These items will be detailed in Abbott-Northwestern's full written report to be submitted within 15 days of discovery. MDH [Minnesota Department of Health] will submit more information as it becomes available. 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 49331 +/-
Where
Abbott Northwestern Hospital Minneapolis, Minnesota (NRC Region 3)
License number:	1007-213-27
Organization:	Minnesota Department Of Health
Reporting

Agreement State
Time - Person (Reporting Time:+9.48 h0.395 days <br />0.0564 weeks <br />0.013 months <br />)
Opened:	Sherrie Flaherty 14:29 Sep 6, 2013
NRC Officer:	Pete Snyder
Last Updated:	Sep 6, 2013
49331 - NRC Website
v • d • e

v t e Emergency Notification System
Abbott Northwestern Hospital with Agreement State
WEEKMONTHYEAR2019-07-26T06:00:00 [Table view]
[ENS list for Abbott Northwestern Hospital]

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