ENS 54757

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v t e ENS Event
05:00 Jun 23, 2020
Title
Event Description	EN Revision Imported Date : 7/22/2020 AGREEMENT STATE REPORT - SUSPECTED DOSE TO WRONG ORGAN The following is a summary of email received from the Oklahoma Department of Environmental Quality (OK DEQ): OK DEQ was just informed that yesterday, June 23, 2020, a medical event may have occurred involving a patient undergoing radiation therapy to the vagina. The treatment plan called for three (3) fractions delivered by a High Dose Rate (HDR) afterloader. After the first fraction was administered, the therapist noted the presence of fecal matter on the applicator. The licensee is assuming that the applicator was placed in the patient's rectum instead of the vagina. The treatment plan estimated a dose of 0.85 Sv to the rectum due to the procedure. The licensee estimates the actual dose delivered, assuming the applicator was in the rectum, to be 1.5 Sv. The licensee is the University of Oklahoma Health Science Center, OK-03176-01. This is a Type A medical broadscope license. OK DEQ will provide more information as it becomes available. * * UPDATE ON 07/21/2020 AT 1549 EDT FROM LIBBY MCCASKILL TO OSSY FONT * * * The following update was received from the OK DEQ via email: OK DEQ is correcting the licensee name and license number. Initially, they were reported as the University of Oklahoma Health Science Center, OK-03176-01. The correct licensee is OU Medicine, Inc., License No. OK-21035-01. Notified R4DO (Drake) and NMSS Event Notification via email. 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 54757 +/-
Where
Ok Deq Rad Management Oklahoma City, Oklahoma (NRC Region 4)
License number:	OK-21035-01
Organization:	Ok Deq Rad Management
Reporting

Agreement State
Time - Person (Reporting Time:+35.52 h1.48 days <br />0.211 weeks <br />0.0487 months <br />)
Opened:	Kevin Sampson 16:31 Jun 24, 2020
NRC Officer:	Bethany Cecere
Last Updated:	Jul 21, 2020
54757 - NRC Website
v • d • e

v t e Emergency Notification System
Oklahoma Department of Environmental Quality with Agreement State
WEEKMONTHYEAR2020-06-23T05:00:00 [Table view]
[ENS list for Oklahoma Department of Environmental Quality]

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