ENS 54775

v t e ENS Event
07:00 Jul 8, 2020
Title	Agreement State Report - Medical Event
Event Description	The following report was received from the State of California via email: On July 10, 2020, the Radiation Safety Officer for the University of California, Los Angeles, notified the Radiologic Health Branch of a Medical Event that occurred with a Varian High Dose Afterloader with an Ir-192 source during an ovarian cancer treatment. The prescribed dose to the intended organ was 24 Gray (2400 rad). Due to an incorrect entry of the catheter length into the treatment delivery system, an unintended dose of 21.8 Gray (2180 rad) was estimated to have been delivered to the large bowel. The dose delivered to the intended organ was initially estimated at 0 Gray (0 rad). The patient and the patient's physician were notified. The licensee's investigation into this medical event is ongoing and will be reviewed further by the California Department of Public Health California 5010 report no: 071020 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 54775 +/-
Where
California Radiation Control Prgm Los Angeles, California (NRC Region 4)
License number:	1335-19
Organization:	California Radiation Control Prgm
Reporting

Agreement State
Time - Person (Reporting Time:+61.3 h2.554 days <br />0.365 weeks <br />0.084 months <br />)
Opened:	Andrew Taylor 20:18 Jul 10, 2020
NRC Officer:	Solomon Sahle
Last Updated:	Jul 10, 2020
54775 - NRC Website
v • d • e

v t e Emergency Notification System
California Radiation Control Program with Agreement State
WEEKMONTHYEAR	Agreement State Report - Pool Water Conductivity Exceeded Limits	Agreement State Report - Radiography Camera Source Retraction Failure 2020-09-03T07:00:00 [Table view]
[ENS list for California Radiation Control Program]

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