ENS 51390
ENS Event | |
|---|---|
04:00 Sep 10, 2015 | |
| Title | Agreement State Report - Medical Treatment Dose Lower than Prescribed |
| Event Description | The following was received from the State of New York via fax:
A New York State licensee informed the Department [New York State Department of Rad Health] of a patient receiving HDR therapy being delivered a fractionated dose that differed from the prescribed fractionated dose by more than 50 percent. The written directive called for a vaginal treatment consisting of three fractions of 1050 cGy per fraction. The second of the three fractions was scheduled on September 10, 2015. Treatment began as planned with both the AU and the AMP at the console. After successful extension and retraction of the dummy source, it was noticed that treatment countdown time was increasing instead of decreasing. The source extension was in contradiction to the console, which indicated 'treatment terminated' although the source extension warning light was also activated near the console. Two AMPs engaged the Emergency-Stop, terminating the treatment and retracting the source to the shielded position. Surveys of the patient and the HDR unit verified that the source was returned to the shielded position. The HDR console indicated that 41.8 seconds had elapsed with source extended. The Patient received an estimated dose of 105 cGy. The patient was informed of the event and no further patients were treated that day. Electa was contacted and a service engineer arrived that same afternoon. He was unable to reproduce the fault condition. Electa is currently investigating the internal performance log of the unit. The physicist performed a complete QC and no aberrations were noted. The HDR unit seems to be performing properly. The last source exchange was on August 14, 2015. Source activity on 9/10/15 was approximately 8 curies. New York event # NY-15-08 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 | |
|---|---|
| Not Provided New York (NRC Region 1) | |
| Organization: | New York City Bureau Of Rad Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+36.68 h1.528 days <br />0.218 weeks <br />0.0502 months <br />) | |
| Opened: | New York State 16:41 Sep 11, 2015 |
| NRC Officer: | Daniel Mills |
| Last Updated: | Sep 11, 2015 |
| 51390 - NRC Website | |
Not Provided with Agreement State | |
WEEKMONTHYEARENS 550062020-11-23T04:00:00023 November 2020 04:00:00
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