ENS 56404

v t e 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.

ENS 56404 +/-
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
v • d • e

v t e Emergency Notification System
Avera Mckennan with 10 CFR 35.3045(a)(1)
WEEKMONTHYEAR2023-03-08T18:30:00 [Table view]
[ENS list for Avera Mckennan]

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