ENS Event | |
|---|---|
07:00 Jun 14, 2023 | |
| Title | Dose Misadministration |
| Event Description | The following information was provided by the Washington State Office of Radiation Protection via email:
On 6/14/2023, a dose misadministration occurred during high dose rate brachytherapy at the Sacred Heart (SH) Radiotherapy Department. The authorized user (AU) intended for 15 Gy to be delivered in three [separate] 5 Gy fractions, but it was planned and delivered in a single 15 Gy treatment. The incident was discovered around 1630 [PDT] the same day. The AU has informed the patient and the referring physician. The SH medical physicist noted that 13 Gy in a single fraction is an effective treatment for the patient's condition (keloids on and around both ears). The 15 Gy was delivered to the keloid surface, and skin tolerance in a single fraction is greater than 25 Gy. Follow up with the patient will be perform in the next few days and ongoing. No other exposure to staff is reported. WA incident number: WA-23-009 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 | |
|---|---|
| Providence Sacred Heart Medical Ctr Spokane, Washington (NRC Region 4) | |
| License number: | WN-M031 |
| Organization: | Wa Office Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+36.88 h1.537 days <br />0.22 weeks <br />0.0505 months <br />) | |
| Opened: | Boris Tsenov 19:53 Jun 15, 2023 |
| NRC Officer: | Ernest West |
| Last Updated: | Jun 15, 2023 |
| 56577 - NRC Website | |
Providence Sacred Heart Medical Ctr with Agreement State | |
WEEKMONTHYEARENS 565772023-06-14T07:00:00014 June 2023 07:00:00
[Table view]Agreement State Dose Misadministration 2023-06-14T07:00:00 | |