ENS 51973

From kanterella

Jump to navigation Jump to search

v t e ENS Event
07:00 May 27, 2016
Title	Agreement State Report - Brachytherapy Underdose
Event Description	The following was received from the State of California via email: The RSO [Radiation Safety Officer] of Loma Linda Medical Center notified the RHB [Radiologic Health Branch] Brea ICE [Inspection, Compliance and Enforcement] office that they believe a medical event occurred on Friday, May 28, 2016. A patient was admitted to the hospital for treatment of carcinoma. The treatment plan involved [10 CFR] 35.400 use of Cs-137 sealed sources for brachytherapy with a tandem and ovoid applicator. The patient's written directive called for 3,460 cGy to target area A (left side tandem), but only approximately 1,500 cGy was delivered. The lower rectum and vaginal areas received more than expected dose, but is believed to be within tolerance. Critical organs of bladder and mid-rectum also received less than expected incidental exposure. The cause of the under dose was human error. The applicator tube used to place the source into the tandem had become crimped by the lead pig during transport to the patients room. During application by the resident physician and medical physicist, the resistance felt during the application process lead them to believe the source was fully deployed to the end of the tube. The chief physicist notified the RSO on Tuesday, May 31, 2016 at 1630 pm, of his dose calculations, in which the hospital began medical event notifications. 5010 Number: 060216 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 51973 +/-
Where
Loma Linda Medical Center San Bernardino, California (NRC Region 4)
License number:	0060-36
Organization:	California Radiation Control Prgm
Reporting

Agreement State
Time - Person (Reporting Time:+157.37 h6.557 days <br />0.937 weeks <br />0.216 months <br />)
Opened:	John G. Fassell 20:22 Jun 2, 2016
NRC Officer:	Dong Park
Last Updated:	Jun 2, 2016
51973 - NRC Website
v • d • e

v t e Emergency Notification System
Loma Linda Medical Center with Agreement State
WEEKMONTHYEAR2021-01-25T08:00:00 [Table view]
[ENS list for Loma Linda Medical Center]

Retrieved from "https://kanterella.com/w/index.php?title=ENS_51973&oldid=82674"

ENS Notification