ENS 55847

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v t e ENS Event
07:00 Apr 8, 2022
Title	Underdose to Patient
Event Description	The following was received from the state of California Radiologic Health Branch (RHB) via email: On 4/14/22, Radiation Safety Officer (RSO) contacted RHB to report a Medical Event associated with a High Dose Rate (HDR) unit. Licensee's written notification on 4/15/22, stated the following: Sometime on Friday, April 8th [2022], an HDR therapist replaced a source transfer tube/catheter with a longer length transfer tube/catheter than intended for the three HDR treatments planned for that day. The difference in lengths was 123 mm. Since the treatment plan was with a shorter transfer tube/catheter, the source didn't make it all the way to the treatment locations and resulted in underdosing the three patients on that day, and likely delivering unplanned doses to non-treatment sites for the three patients. The error was discovered on Wednesday, April 13th, as another HDR therapist was getting ready for an HDR treatment. No HDR treatments had occurred since Friday, April 8. The first therapist wasn't certain if she changed the transfer tube/catheter in the morning or after the patients, but she thinks she likely changed it in the morning. The licensee is still evaluating the delivered doses to the patients treated on that Friday, but at least two of them are believed to have received an underdose that is reportable. The doses to non-treatment sites have not been fully evaluated. All three patients and their referring physicians were notified on Thursday, April 14th. RHB is continuing to follow up with the investigation. California Event Number: 041422 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 55847 +/-
Where
Sf Medical Center San Francisco, California (NRC Region 4)
License number:	1725-38
Organization:	California Radiation Control Prgm
Reporting

Agreement State
Time - Person (Reporting Time:+179.97 h7.499 days <br />1.071 weeks <br />0.247 months <br />)
Opened:	K. Arunika Hewadikaram 18:58 Apr 15, 2022
NRC Officer:	Thomas Herrity
Last Updated:	Apr 15, 2022
55847 - NRC Website
v • d • e

v t e Emergency Notification System
Sf Medical Center with Agreement State
WEEKMONTHYEAR2022-04-08T07:00:00 [Table view]
[ENS list for Sf Medical Center]

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