ENS 54686

v t e ENS Event
07:00 Mar 20, 2020
Title	Agreement State Report - Brachytherapy Underdose Due to an Error in the Treatment Plan
Event Description	The following information is summarized from the report received from the state of Nevada via email: A patient was scheduled to receive 34 Gy to the treatment site via a Nucletron brachytherapy device containing 444 GBq of Ir-192. The dose was to be received via two fractions-a-day for 5 days. All fractions were delivered as scheduled. During the post-treatment review, it was determined that the delivery device was placed 8 mm proximal to the intended treatment site due to a digitization error in the treatment plan. This resulted in the patient receiving 71 percent of the intended dose. At the time of the report, there were no acute ill-effects on the patient. NMED Report No.: NV200006 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 54686 +/-
Where
Nv Div Of Rad Health Las Vegas, Nevada (NRC Region 4)
License number:	03-12-0491-01
Organization:	Nv Div Of Rad Health
Reporting

Agreement State
Time - Person (Reporting Time:+996.83 h41.535 days <br />5.934 weeks <br />1.365 months <br />)
Opened:	Corey Creveling 19:50 Apr 30, 2020
NRC Officer:	Howie Crouch
Last Updated:	Apr 30, 2020
54686 - NRC Website
v • d • e

v t e Emergency Notification System
Nv Div Of Rad Health with Agreement State
WEEKMONTHYEAR2020-04-29T07:00:00 [Table view]
[ENS list for Nv Div Of Rad Health]

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