ENS 56805

v t e ENS Event
04:00 Oct 20, 2023
Title	Patient Overexposure
Event Description	The following information was provided by the Florida Bureau of Radiation Control [the Bureau] via email: This is a medical event resulting from an overexposure of the breast. A 52-year old female was being treated with 10 fractions of High Dose Rate I-192. The total dose was to be 34 Gy total. The estimated actual dose was 30 percent greater. The delivery system is on a windows XP based personal computer and due to computer security, a windows XP based computer cannot be on the network. Because of this [configuration], the planning and delivery systems are not linked. [As a result,] staff did not verify the dwell times between the planning and delivery systems, resulting in using an incorrect dwell time. Eight (8) fractions were delivered with incorrect dwell time before this was noted. 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 56805 +/-
Where
Florida Cancer Spec. &Amp; Res. Inst. Orlando, Florida (NRC Region 1)
License number:	3897-2
Organization:	Florida Bureau Of Radiation Control
Reporting

Agreement State
Time - Person (Reporting Time:+8.73 h0.364 days <br />0.052 weeks <br />0.012 months <br />)
Opened:	John A. Williamson 12:44 Oct 20, 2023
NRC Officer:	Lawrence Criscione
Last Updated:	Oct 20, 2023
56805 - NRC Website
v • d • e

v t e Emergency Notification System
with Agreement State
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