ENS Event | |
|---|---|
05:00 Feb 11, 2022 | |
| Title | Dose to an Incorrect Treatment Site |
| Event Description | The following report was received from the Pennsylvania Department of Bureau Radiation Protection (the Department) via email:
The Department [DEP] received notification from a licensee on February 15, 2022, of medical event involving dose to an incorrect treatment site. An Elekta/Nucletron Remote Afterloader containing 6.421 Curies of iridium 192 (serial number V3/ 10799) with a Valencia skin applicator was to treat the lower third nasal dorsum with 600 cGy. However, the prescribing physician specified the right nasal sidewall. Therefore, the patient received 600 cGy to her lower 3rd nasal dorsum and not right nasal sidewall. The patient and prescribing physician were informed on February 14, 2022. The patient is being monitored and at this time no adverse effects are evident. The DEP is currently in contact with the licensee and will update this event as soon as more information is provided. Pennsylvania Event Report Number: PA220007 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 | |
|---|---|
| Northeast Radiation Oncology Center Dunmore, Pennsylvania (NRC Region 1) | |
| License number: | PA-1541 |
| Organization: | Pa Bureau Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+125.63 h5.235 days <br />0.748 weeks <br />0.172 months <br />) | |
| Opened: | John Chippo 10:38 Feb 16, 2022 |
| NRC Officer: | Mike Stafford |
| Last Updated: | Feb 16, 2022 |
| 55740 - NRC Website | |
Northeast Radiation Oncology Center with Agreement State | |
WEEKMONTHYEARENS 557402022-02-11T05:00:00011 February 2022 05:00:00
[Table view]Agreement State Dose to an Incorrect Treatment Site 2022-02-11T05:00:00 | |