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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 55236 | 4 May 2021 20:30:00 | Agreement State | Misadministration During Brachytherapy Treatment | The following was received from the State of Florida: Administration of radiation and subsequent received dose to an incorrect area of patient during a gynecological brachytherapy treatment on 5/4/21. The Radiation Safety Officer (RSO) reported that a source transfer tube of incorrect length (approximately 12 cm too long) was used resulting in exposure misadministration. The patient was notified. The attending physician and RSO advised patient that no adverse health effects are expected. Source Serial #: 02-01-3155-001-020321-11408-84 Maximum Dose Received: 8-9 Gray, Shallow. Florida Incident Number: FL21-056 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. |