ENS 51798

v t e ENS Event
04:00 Mar 15, 2016
Title	Agreement State Report - Medical Underdose
Event Description	The following was received from Florida via email: On Tuesday March 15, 2016, a patient being treated for skin cancer on the right side of his mandible using a Valencia applicator was treated using the plan time from another patient who is being treated for the left leg also using a Valencia applicator. The short fall difference in time was 8.2 seconds, meaning that the patient treated for the right mandible was given 3.2% less radiation than what was correctly calculated for. As a plan of action, the patient as well as the attending physician will be notified of the occurrence, and a 'time-out' policy will be implemented for all HDR [high does rate brachytherapy] treatments to ensure that the correct patient, date of birth, patient number, plan number, date of the plan, and treatment location are being treated prior to the actual treatments. A policy will be formally drafted to this effect and placed into the departmental policy and procedures manual. [The prescribing physician] will decide whether or not to make up the short fall in the treatment dose after consultation with the patient. Florida Incident # FL16-043 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 51798 +/-
Where
Hesek & Kepes Radiation Oncology Plant City, Florida (NRC Region 1)
License number:	4302-1
Organization:	Florida Bureau Of Radiation Control
Reporting

Agreement State
Time - Person (Reporting Time:+61.55 h2.565 days <br />0.366 weeks <br />0.0843 months <br />)
Opened:	Tim Dunn 17:33 Mar 17, 2016
NRC Officer:	Daniel Mills
Last Updated:	Mar 17, 2016
51798 - NRC Website
v • d • e

v t e Emergency Notification System
Hesek & Kepes Radiation Oncology with Agreement State
WEEKMONTHYEAR2016-03-15T04:00:00 [Table view]
[ENS list for Hesek & Kepes Radiation Oncology]

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