ENS 49649

v t e ENS Event
05:00 Nov 21, 2013
Title	Agreement State Report - Hdr Brachytherapy Source Placed Incorrectly
Event Description	Description of incident: HDR brachytherapy treatment of the bronchial, tracheal area. The source was placed incorrectly, resulting in underdose to intended treatment area. An additional treatment fraction will be prescribed to compensate for underdose to intended treatment area. Underdose was discovered on 1st of 3 fractions, prior to delivery of 2nd fractions. Sequelea: No adverse effects expected as a result of medical event, since the patient is terminally ill. 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 49649 +/-
Where
Memorial Sloan-Kettering Cancer Center New York, New York (NRC Region 1)
License number:	75-2968-01
Organization:	New York City Bureau Of Rad Health
Reporting

Agreement State
Time - Person (Reporting Time:+655.37 h27.307 days <br />3.901 weeks <br />0.898 months <br />)
Opened:	Tobias Lickerman 12:22 Dec 18, 2013
NRC Officer:	John Shoemaker
Last Updated:	Dec 18, 2013
49649 - NRC Website
v • d • e

v t e Emergency Notification System
Memorial Sloan-Kettering Cancer Center with Agreement State
WEEKMONTHYEAR2013-11-21T05:00:00 [Table view]
[ENS list for Memorial Sloan-Kettering Cancer Center]

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