ENS 52447

v t e ENS Event
05:00 Nov 23, 2016
Title	Agreement State Report - Medical Event Involving High Dose Rate Therapy Dose to an Unintended Location
Event Description	The following information was obtained from the state of New Hampshire via facsimile: NH Radiological Health Section 'Agency' was notified on November 23 by Chief Physicist followed by an e-mail from the Radiation Safety Officer (RSO) at Mary Hitchcock Memorial Hospital on November 24, 2016, of the HDR [high dose rate therapy] dose to an unintended location. The patient and the Authorized User were notified of the error and the correct fraction was administered. The licensee's RSO conducted an investigation and interviewed persons involved with the administration. A written explanation of the event was obtained. Cause of incident was identified as equipment malfunction (a deformed transfer tube). New Hampshire Event Report ID No.: NH-16-001 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 52447 +/-
Where
Mary Hitchcock Memorial Hospital Lebanon, New Hampshire (NRC Region 1)
License number:	130R
Organization:	Nh Dept Of Health & Human Services
Reporting

Agreement State
Time - Person (Reporting Time:+659.02 h27.459 days <br />3.923 weeks <br />0.903 months <br />)
Opened:	Augustinus Ong 16:01 Dec 20, 2016
NRC Officer:	Howie Crouch
Last Updated:	Dec 20, 2016
52447 - NRC Website
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v t e Emergency Notification System
Mary Hitchcock Memorial Hospital with Agreement State
WEEKMONTHYEAR2023-10-05T04:00:00 [Table view]
[ENS list for Mary Hitchcock Memorial Hospital]

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