ENS 50011

v t e 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.

ENS 50011 +/-
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
v • d • e

v t e Emergency Notification System
Miami Neuroscience Center - Larkin Community Hospital with Agreement State
WEEKMONTHYEAR2014-04-08T12:12:00 [Table view]
[ENS list for Miami Neuroscience Center - Larkin Community Hospital]

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