ENS 54728

v t e ENS Event
20:30 May 26, 2020
Title	Agreement State Report - Possible Administration at the Wrong Treatment Site
Event Description	The following information was received from the state of Alabama via email: The Alabama Department of Public Health Office of Radiation Control was notified on May 26, 2020, at about 1620 CDT by the Radiation Safety Officer (RSO) of the University of South Alabama Health University Hospital (license 584) of a possible misadministration via HDR [high dose rate] afterloader. The RSO stated that the patient was apparently treated at the wrong treatment site on May 26, 2020 around 1530 CDT; the prescribed dose for the fraction was 700 cGy (treatment course to total 2100 cGy). The licensee is currently working to reconstruct dosimetry at the time of this report, and is unsure of the variance from the prescribed dose. The licensee is authorized to possess an Elekta 136149A02, with a maximum of 12 Ci of Ir-192. Alabama Incident Report No.: 20-09. 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 54728 +/-
Where
Alabama Radiation Control Mobile, Alabama (NRC Region 1)
License number:	584
Organization:	Alabama Radiation Control
Reporting

Agreement State
Time - Person (Reporting Time:+11.6 h0.483 days <br />0.069 weeks <br />0.0159 months <br />)
Opened:	Cason Coan 08:06 May 27, 2020
NRC Officer:	Brian Lin
Last Updated:	May 27, 2020
54728 - NRC Website
v • d • e

v t e Emergency Notification System
Alabama Office of Radiation Control with Agreement State
WEEKMONTHYEAR2020-08-03T22:00:00 [Table view]
[ENS list for Alabama Office of Radiation Control]

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