ENS 50793

v t e ENS Event
13:00 Feb 6, 2015
Title	Medical Misadministration During Brachytherapy
Event Description	A patient underwent brachytherapy utilizing a vaginal cylinder. The prescribed dose was 5.5 Gray (550 rem) to the target volume, but due to mispositioning of the source, the target volume received only a negligible dose. The source was positioned such that the skin received a dose of up to 2.5 Gray (250 rem). The patient and prescribing physician have been notified. The patient is unlikely to suffer any permanent effects, but could experience mild erythema. The patient has been scheduled for an additional treatment. The hospital will take steps to prevent a future recurrence before the next patient is treated. 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 50793 +/-
Where
Mclaren Medical Center - Bay Region Bay City, Michigan (NRC Region 3)
License number:	21-18585-01
Organization:	Mclaren Medical Center - Bay Region
Reporting

10 CFR 35.3045(a)(1)
Time - Person (Reporting Time:+5.65 h0.235 days <br />0.0336 weeks <br />0.00774 months <br />)
Opened:	Matt Buczek 18:39 Feb 6, 2015
NRC Officer:	Daniel Mills
Last Updated:	Feb 6, 2015
50793 - NRC Website
v • d • e

v t e Emergency Notification System
Mclaren Medical Center - Bay Region with 10 CFR 35.3045(a)(1)
WEEKMONTHYEAR2015-02-06T13:00:00 [Table view]
[ENS list for Mclaren Medical Center - Bay Region]

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