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. |
| 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 | |
Mary Hitchcock Memorial Hospital with Agreement State | |
WEEKMONTHYEARENS 567822023-10-05T04:00:0005 October 2023 04:00:00
[Table view]Agreement State Agreement State - Greater than Anticipated Dose to NON-TARGET Organ ENS 524472016-11-23T05:00:00023 November 2016 05:00:00 Agreement State Agreement State Report - Medical Event Involving High Dose Rate Therapy Dose to an Unintended Location ENS 424402006-03-03T05:00:0003 March 2006 05:00:00 Agreement State Agreement State Report - Medical Event Involving the Wrong Radiopharmaceutical 2023-10-05T04:00:00 | |