ENS Event | |
|---|---|
17:20 Jul 10, 2014 | |
| Title | Patient Received Less than Prescribed Dose |
| Event Description | A patient undergoing High Dose Rate Brachytherapy using Ir-192 was prescribed 700 cGy per fraction and only received 700 cGy to 60% of the planned volume.
The patient was scheduled for two treatments. The first treatment was successfully administered to the patient on 6/26/14. When the patient returned for the second treatment on 7/10/14 the HDR afterloader was loaded with the treatment plan for the original treatment instead of the second treatment. This resulted in the patient not receiving the full prescribed treatment. The licensee discovered the problem during an audit when the number of catheters did not match. There are no adverse health effects expected as a result of this treatment. The licensee has contacted the vender to determine a way to remove old treatment plans from the machine to ensure this does not happen in the future. 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 | |
|---|---|
| Botsford Hospital Farmington Hills, Michigan (NRC Region 3) | |
| License number: | 21-08892-01 |
| Organization: | Botsford Hospital |
| Reporting | |
| 10 CFR 35.3045(a)(3) | |
| Time - Person (Reporting Time:+839.95 h34.998 days <br />5 weeks <br />1.151 months <br />) | |
| Opened: | Teamour Nurushev 17:17 Aug 14, 2014 |
| NRC Officer: | Charles Teal |
| Last Updated: | Aug 14, 2014 |
| 50369 - NRC Website | |
Botsford Hospital with 10 CFR 35.3045(a)(3) | |
WEEKMONTHYEARENS 503692014-07-10T17:20:00010 July 2014 17:20:00
[Table view]10 CFR 35.3045(a)(3) Patient Received Less than Prescribed Dose 2014-07-10T17:20:00 | |