ENS Event | |
|---|---|
18:30 Mar 8, 2023 | |
| Title | Medical Event - Dosage Not in Accordance with the Written Directive |
| Event Description | The following information was obtained from the licensee via telephone in accordance with Headquarters Operations Officers Report Guidance:
On March 8, 2023 at 1230 CST, three of nine catheters of a Venezia applicator with 6.8 Ci of Ir-192 were incorrectly mapped to channels in the after loader. This resulted in a dose to the patient that was not in accordance with the written directive. This was discovered on March 9, 2023. The patient and ordering physician were notified. 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 | |
|---|---|
| Avera Mckennan Sioux Falls, South Dakota (NRC Region 4) | |
| License number: | 401657101 |
| Organization: | Avera Mckennan |
| Reporting | |
| 10 CFR 35.3045(a)(1) | |
| Time - Person (Reporting Time:+41 h1.708 days <br />0.244 weeks <br />0.0562 months <br />) | |
| Opened: | Tracy Hollingshead 11:30 Mar 10, 2023 |
| NRC Officer: | Bill Gott |
| Last Updated: | Mar 10, 2023 |
| 56404 - NRC Website | |
Avera Mckennan with 10 CFR 35.3045(a)(1) | |
WEEKMONTHYEARENS 564042023-03-08T18:30:0008 March 2023 18:30:00
[Table view]10 CFR 35.3045(a)(1) Medical Event - Dosage Not in Accordance with the Written Directive 2023-03-08T18:30:00 | |