ENS 56224

v t e ENS Event
05:00 Nov 14, 2022
Title	Wrong Initial Dose to Patient
Event Description	The following report was received via email from the Tennessee Division of Radiological Health: Medical Physicist for Holston Valley Medical Center reported that a patient was mistakenly given all fractions of a cervical treatment on November 14, 2022. The patient was scheduled for five 600 centigray (cGy) fractions of Ir-192 for a total of 3000 cGy. The medical physicist misread the prescription and gave the full 3000 cGy in the initial dose. As of November 15, 2022, the patient had not been notified. However, the patient will be returning on November 16, 2022, for the next treatment. Corrective actions or reports will be updated with a report within 30 days." Tennessee Event Number: TN-22-069 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 56224 +/-
Where
Holston Valley Medical Center Kingsport, Tennessee (NRC Region 1)
License number:	R-82031
Organization:	Tennessee Div Of Rad Health
Reporting

Agreement State
Time - Person (Reporting Time:+59.03 h2.46 days <br />0.351 weeks <br />0.0809 months <br />)
Opened:	Andrew Holcomb 16:02 Nov 16, 2022
NRC Officer:	Brian P. Smith
Last Updated:	Nov 16, 2022
56224 - NRC Website
v • d • e

v t e Emergency Notification System
Holston Valley Medical Center with Agreement State
WEEKMONTHYEAR2022-11-14T05:00:00 [Table view]
[ENS list for Holston Valley Medical Center]

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