ENS 49939

v t e ENS Event
04:00 Mar 11, 2012
Title	Agreement State Report - Error in Dose Calculation and Underdose Administration
Event Description	The following was received from the Commonwealth of Virginia via fax: Event description: On March 18, 2014, the licensee identified an error in a dose calculation for high dose rate (HDR) treatments administered to a patient on March 11-12. The initial report from the licensee indicates the patient was administered two out of a total of six prescribed fractionated doses. An error was made in planning the correct dwell position for the two fractions. The administered dose differed from the prescribed dose (was less than) by more than 20 percent. The licensee plans to correct for the underdose during the remaining fractions. The licensee is investigating if the dose to tissues other than the treatment site may have met the definition of a medical event. Virginia Event Report ID No.: VA-14-0002 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 49939 +/-
Where
Inova Fairfax Hospital Falls Church, Virginia (NRC Region 1)
License number:	610-116-1
Organization:	Virginia Rad Materials Program
Reporting

Agreement State
Time - Person (Reporting Time:+17750.52 h739.605 days <br />105.658 weeks <br />24.315 months <br />)
Opened:	Charles Coleman 17:31 Mar 20, 2014
NRC Officer:	John Shoemaker
Last Updated:	Mar 20, 2014
49939 - NRC Website
v • d • e

v t e Emergency Notification System
Inova Fairfax Hospital with Agreement State
WEEKMONTHYEAR2014-08-29T04:00:00 [Table view]
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