ENS Event | |
|---|---|
12:12 Apr 8, 2014 | |
| Title | Agreement State Report Involving Palliative Dose Administered to the Wrong Treatment Site |
| Event Description | The following report was received from the State of Florida via email:
This treatment was set up by the treatment planner taking into account the previous two treatments performed on the right side back in 2008 and 2007. The treatment planner did not realize that the pain had resolved on the right side and that the treatment was to be performed on the left side. The treatment was reviewed and signed according to protocol and was started by [the Authorized User] at 8:12 am. The 19.14 minute treatment was stopped at 1.72 minutes when it was realized that the patient was to be treated on the left side. At 8:42 am [the Authorized User] had [the Neurosurgeon] inform the patient that we interrupted the treatment because we had started treating the right side instead of the left side. The treatment planner created a treatment plan for the left side, the patient was treated and the stereotactic frame was removed at 10:00 am. This Medical Event will have no detrimental effects on the patient. No further action will be taken on. Florida Incident Number: FL14-035 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 | |
|---|---|
| Miami Neuroscience Center - Larkin Community Hospital South Miami, Florida (NRC Region 1) | |
| License number: | 2825-2 |
| Organization: | Florida Bureau Of Radiation Control |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+5.02 h0.209 days <br />0.0299 weeks <br />0.00688 months <br />) | |
| Opened: | Rich A. Davis 17:13 Apr 8, 2014 |
| NRC Officer: | Steve Sandin |
| Last Updated: | Apr 8, 2014 |
| 50011 - NRC Website | |
Miami Neuroscience Center - Larkin Community Hospital with Agreement State | |
WEEKMONTHYEARENS 500112014-04-08T12:12:0008 April 2014 12:12:00
[Table view]Agreement State Agreement State Report Involving Palliative Dose Administered to the Wrong Treatment Site 2014-04-08T12:12:00 | |