ENS 50126

v t e ENS Event
04:00 May 19, 2014
Title	Agreement State Report - Patient Received Unintended Shallow Skin Dose
Event Description	The following information was received from the State of Florida via email: [On] Monday May 19, 2014, on follow-up visit, the patient presented with burns on the thighs and the labia. [The] Radiation Oncologist ordered an immediate investigation: High Dose Remote After Loader (HDR) Prescription event. No further action will be taken on this incident. The patient received 21Gy in three (3) fractions. Following completion of treatment, a review of the Treatment Planning on Oncentra TPS revealed a reference length of 1223 mm instead of 1323 (expected value +/- 1 mm). The reference length used in the TPS was measured prior to CT with the SPS (Source Position Simulator) by two physicists. Therefore, the radiation was 10 cm short from reaching the target which explains the occurrence of burns on the patient's thighs. The three prescribed fractions were delivered on: 3/31/14, 04/07/14 and 04/14/14. Florida Incident Number: FL14-043 The device used is an HDR containing Ir-192 with a Capri Applicator. A corrective action plan has been developed by the licensee to prevent recurrence. The licensee informed both the prescribing physician and the patient. No long-term adverse health effects are expected. 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 50126 +/-
Where
Watson Clinic Lakeland, Florida (NRC Region 1)
License number:	2619-1
Organization:	Florida Bureau Of Radiation Control
Reporting

Agreement State
Time - Person (Reporting Time:+35 h1.458 days <br />0.208 weeks <br />0.0479 months <br />)
Opened:	Richard Davis 15:00 May 20, 2014
NRC Officer:	Steve Sandin
Last Updated:	May 20, 2014
50126 - NRC Website
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v t e Emergency Notification System
Watson Clinic with Agreement State
WEEKMONTHYEAR2014-05-19T04:00:00 [Table view]
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