ENS 53226

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v t e ENS Event
06:00 Feb 21, 2018
Title	Agreement State Report - Medical Event
Event Description	The following was received via email from the State of Texas: On February 22, 2018, the licensee notified the Agency [Texas Department of State Health Services] that it had made the determination a medical event had occurred. On February 19, 2018, a patient received first fraction of treatment plan delivered by high dose rate afterloader (HDR) utilizing iridium-192. The patient returned on February 21st for the second fraction. The physicist was reviewing the information prior to treatment and found an error had occurred with the first treatment. The licensee investigated and conducted dose reconstruction. The licensee's investigation revealed that the physicist performing the digitization of the 13 channels on HDR applicator had digitized channel #12 and when he went to channel #13 he failed to 'tell' the machine, which added the 5.5 centimeters that should have been in channel #13 onto channel #12. There was a high dwell time at the end of the extended 5.5 centimeters which resulted in a dose to tissue outside the target volume that exceeds 50 rem and 50% or more of the dose expected. The licensee reported a small amount of tissue received, and should tolerate, the extra dose. The referring physician has been notified. More information will be provided as it is obtained and in accordance with SA-300. Texas Incident #: I -9546 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 53226 +/-
Where
Texas Oncology Pa Austin, Texas (NRC Region 4)
License number:	06090
Organization:	Texas Dept Of State Health Services
Reporting

Agreement State
Time - Person (Reporting Time:+36.85 h1.535 days <br />0.219 weeks <br />0.0505 months <br />)
Opened:	Karen Blanchard 18:51 Feb 22, 2018
NRC Officer:	Steven Vitto
Last Updated:	Feb 22, 2018
53226 - NRC Website
v • d • e

v t e Emergency Notification System
Texas Oncology Pa with Agreement State
WEEKMONTHYEAR2019-07-30T05:00:00 [Table view]
[ENS list for Texas Oncology Pa]

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ENS Notification