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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 50793 | 6 February 2015 13:00:00 | 10 CFR 35.3045(a)(1) | Medical Misadministration During Brachytherapy | A patient underwent brachytherapy utilizing a vaginal cylinder. The prescribed dose was 5.5 Gray (550 rem) to the target volume, but due to mispositioning of the source, the target volume received only a negligible dose. The source was positioned such that the skin received a dose of up to 2.5 Gray (250 rem). The patient and prescribing physician have been notified. The patient is unlikely to suffer any permanent effects, but could experience mild erythema. The patient has been scheduled for an additional treatment. The hospital will take steps to prevent a future recurrence before the next patient is treated. 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. |