ENS 49523

v t e ENS Event
05:00 Oct 25, 2013
Title	Administration of Less than the Prescribed Dose to a Patient
Event Description	The following report was received via e-mail: 10-25-2013 (Friday) HDR [High Dose Rate] treatment to right breast with SAVI 9 Channel HDR unit: 1st channel treated appropriately but only fractional treatments to channel 2-8 of less than 50% of prescribed dose were delivered. Problems with the applicator's curvature caused source delivery problems. The manufacturer (Varian) was contacted but was unable to arrive before the next Monday. 10-28-2013 (Monday) Licensee made another attempt, but again only fractional treatments to channel 2-8 of less than 50% of prescribed dose was delivered. 10-29-2013 (Tuesday) The patient was taken to another Mount Carmel facility (MC West), parameters were recalculated and patient treatment was successfully concluded. The licensee stated they expect that no harm was done to the patient. The licensee stated that they didn't understand that this event was reportable until they were advised by Varian it was an equipment failure so it was a 24 hr. reportable event. Event ID No: OH130015 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 49523 +/-
Where
Mount Carmel Health At St. Ann'S Cancer Center Westerville, Ohio (NRC Region 3)
License number:	02120250034
Organization:	Ohio Bureau Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+347.5 h14.479 days <br />2.068 weeks <br />0.476 months <br />)
Opened:	Chuck Mccracken 17:30 Nov 8, 2013
NRC Officer:	Dong Park
Last Updated:	Nov 8, 2013
49523 - NRC Website
v • d • e

v t e Emergency Notification System
Mount Carmel Health At St. Ann'S Cancer Center with Agreement State
WEEKMONTHYEAR2013-10-25T05:00:00 [Table view]
[ENS list for Mount Carmel Health At St. Ann'S Cancer Center]

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