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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 52816 | 19 June 2017 06:00:00 | Agreement State | Agreement State Report - Dose Delivered to Site Adjacent to Intended Target | The following State of Utah report was received by email: The licensee delivered a 500 cGy fraction of HDR (High Dose Rate) brachytherapy to a site adjacent to the intended target. This treatment was a supplemental boost to external beam radiotherapy, and the mistreated volume was included in the target volume of the external beam plan. The State of Utah was notified of the event on June 21, 2017 by electronic mail opened at 1125 MDT. Utah Event Report ID No: will be provided in follow up report.
The following information was received via e-mail: The licensee name needs to be changed from 'University of Utah, Radiological Health Department' to 'Jordan Valley Medical Center, LP'. Notified the R4DO (Gaddy) and NMSS Events Notification via e-mail. 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. |