ENS Event | |
|---|---|
05:00 Mar 7, 2019 | |
| Title | Agreement State Report - Misadministration of Dose to Patient |
| Event Description | The following was received via e-mail:
On March 14, 2019, the Texas Department of Health Services was notified by the licensee's radiation safety officer (RSO) that a therapy event had occurred. A patient was scheduled for three fractions using a high dose rate after loader containing a 6.8 curie iridium-192 source. Multiple catheters were to be used. On March 14, 2019, prior to the third fraction, the licensee determined that one of the catheters was shorter than the length required and the patient received 350 centigrays (50 percent) of the prescribed dose to the thigh resulting in the target tissue receiving 50 percent of the prescribed dose (350 centigrays). The third fraction was not administered. The RSO stated they intended to create a new treatment plan to correct the error and insure the intended area receives the correct dose. Additional information will be provided as it is received in accordance with SA-300. Texas Incident Number: 9665 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 | |
|---|---|
| Texas Oncology Pa Austin, Texas (NRC Region 4) | |
| License number: | L05108 |
| Organization: | Texas Dept Of State Health Services |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+180.08 h7.503 days <br />1.072 weeks <br />0.247 months <br />) | |
| Opened: | Art Tucker 16:05 Mar 14, 2019 |
| NRC Officer: | Joanna Bridge |
| Last Updated: | Mar 14, 2019 |
| 53932 - NRC Website | |
Texas Oncology Pa with Agreement State | |
WEEKMONTHYEARENS 542312019-07-30T05:00:00030 July 2019 05:00:00
[Table view]Agreement State Agreement State Report - Incorrect Dosage Administered ENS 539322019-03-07T05:00:0007 March 2019 05:00:00 Agreement State Agreement State Report - Misadministration of Dose to Patient ENS 538362019-01-18T06:00:00018 January 2019 06:00:00 Agreement State En Revision Imported Date 2/22/2019 ENS 532262018-02-21T06:00:00021 February 2018 06:00:00 Agreement State Agreement State Report - Medical Event 2019-07-30T05:00:00 | |