ENS 50991

v t e ENS Event
07:00 Apr 15, 2015
Title	Agreement State Report - Source Moved During Medical Treatment
Event Description	On 4-15-15 the patient was to receive a fractionated dose of 4 Grays to the 'vaginal cuff' region using a 10.175 Curie Ir-192 source. The dose was to be administered using a Varian Model VariSource 200t remote HDR [High Dose Rate] afterloader, serial number 600349. The plan was to administer 6 radiation treatments using a cylinder applicator and holder, the treatment length intended to be 5 cm. Imaging was done after placement of the cylinder prior to treatment to verify location, however, post-treatment imaging showed that the cylinder applicator had come loose from the holder and shifted 3 cm. This was the first of the six fractions. Hospital staff physicists are currently working to determine the delivered dose to the target and why the shift occurred. Physician notification has not been verified at this time. The patient has been notified. 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 50991 +/-
Where
Oregon Health And Science University Portland, Oregon (NRC Region 4)
License number:	ORE-90013
Organization:	Or Dept Of Health Rad Protection
Reporting

Agreement State
Time - Person (Reporting Time:+53.72 h2.238 days <br />0.32 weeks <br />0.0736 months <br />)
Opened:	Daryl Leon 12:43 Apr 17, 2015
NRC Officer:	Mark Abramovitz
Last Updated:	Apr 17, 2015
50991 - NRC Website
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v t e Emergency Notification System
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