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. |
| 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 | |
Abbott Northwestern Hospital with Agreement State | |
WEEKMONTHYEARENS 556572019-07-26T06:00:00026 July 2019 06:00:00
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