ENS 57581

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v t e ENS Event
05:00 Feb 25, 2025
Title	Medical Event
Event Description	The following is a summary of information provided by the State of Florida, Bureau of Radiation Control (the BRC) via email: [BRC was notified of a medical event involving a high dose rate (HDR) prostate treatment that] occurred on 2/25/25, was identified during the weekend of 3/1/25 to 3/2/25, and was determined to have been a medical event by the facility on 3/3/25. During [delivery of] the second fraction of two fractions, Comprehensive Hematology Oncology incorrectly typed the catheter length into the procedure's software. This resulted in the dose being received 5 cm short of the intended location. The prostate received no dose during this fraction, and the rectum received an estimated 60 percent of its expected dose. The patient and primary physician have been notified. The second fraction has been rescheduled. The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: The prescribed dose for the second fraction of the HDR prostate treatment was unknown at the time of the notification. This event is similar but involved a different patient than EN 57580 (FL25-018). Florida Incident Number: FL25-019 * * UPDATE ON 03/04/2025 AT 0847 EST FROM MONROE COOPER TO ROBERT THOMPSON * * * Current information, retrieved by BRC, states that the intended total dose was 2700 cGy delivered over two fractions. 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 57581 +/-
Where
Comprehensive Hematology Oncology Trinity, Florida (NRC Region 1)
License number:	4657-3
Organization:	Florida Bureau Of Radiation Control
Reporting

Agreement State
Time - Person (Reporting Time:+151.65 h6.319 days <br />0.903 weeks <br />0.208 months <br />)
Opened:	Monroe A. Cooper 12:39 Mar 3, 2025
NRC Officer:	Josue Ramirez
Last Updated:	Mar 4, 2025
57581 - NRC Website
v • d • e

v t e Emergency Notification System
Comprehensive Hematology Oncology with Agreement State
WEEKMONTHYEAR2025-02-25T05:00:00 [Table view]
[ENS list for Comprehensive Hematology Oncology]

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ENS Notification