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. |
| 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 | |
Nv Div Of Rad Health with Agreement State | |
WEEKMONTHYEARENS 546852020-04-29T07:00:00029 April 2020 07:00:00
[Table view]Agreement State Agreement State Report - Medical Underdose During Brachytherapy Treatment ENS 546862020-03-20T07:00:00020 March 2020 07:00:00 Agreement State Agreement State Report - Brachytherapy Underdose Due to an Error in the Treatment Plan 2020-04-29T07:00:00 | |