Semantic search
| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 49237 | 1 August 2013 05:00:00 | Agreement State | Agreement State Report - Wrong Fractional Dose Administered to Patient | The licensee reported the administration of a 700 cGy fractional dose instead of the 500 cGy prescribed fractional dose to a patient during GYN treatment on 8/1/13. The 700 cGy fraction was prepared for another patient. The isotope involved was Ir-192. The fraction was the second of a three fraction total dose of 1500 cGy. The final fraction will be adjusted so that the total dose to the patient is 1500 cGy. The prescribing physician had been informed. The patient will be informed of the adjustment prior to administration of the final fraction on 8/8/13. There are no anticipated adverse consequences to the patient. The cause is under investigation and the licensee is still discussing potential corrective actions. 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 43422 | 14 June 2007 15:30:00 | Agreement State | Agreement State Report - Potential Personnel Overexposure | The licensee's RSO received a phone call from Landauer at 1030 this morning to report a badge which had a deep dose reading of 6437 milliRem, an eye dose reading of 6437 milliRem, and a shallow dose reading of 6400 milliRem. The badge was assigned to the Chief of Surgery for the licensee for the month of January 2006. The RSO is investigating the cause for the fifteen month delay (January 2006 till June 2007) in processing the badge. Landauer told the RSO that this was a "dynamic" exposure to the badge meaning that the badge was moving during the time period of exposure. Iowa Item Number IA-070001.
Upon further investigation of it was determined that the exposure is solely due to fluoroscopic procedures. Radiation generated from fluoroscopic equipment is not regulated by the NRC. Due to this fact the event should not have been reported to the NRC and is retracted. The State of Iowa will continue to investigate this matter with its licensee. Notified R3DO (Louden) and FSME EO (Flannery). |