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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 56240 | 16 November 2022 05:00:00 | Agreement State | Patient Underdose | The following information was received from the Georgia Radioactive Materials Program via email: We received an emailed report of a misadministration, where there was over 50 percent deviation of the prescribed dose. The patient received only 10 percent of the (redacted) prescribed fractioned dose due to equipment malfunction. The patient is scheduled to receive the remainder of the dose at a later time. The licensee will conduct a thorough investigation and provide a formal report as soon as possible. We are still pending the source activity information and event date. We will update as more information comes in. Georgia incident no.: 61
The following is a synopsis developed from information provided by the Georgia Radioactive Materials Program via email: Was source able to be retracted to safe position? Yes Manufacturer and Model number of HDR: Elekta's Flexitron Serial number: 00625 Source activity (8.9 Ci); Prescribed dose (750 cGy); Delivered dose (12.7 cGy) Root Cause: Equipment failure. Assessment by Elekta's field service engineer determined that the Flexitron selector assembly should be recalibrated including lubrication of all brackets on the assembly. Corrective Action: Recalibration. Following recalibration of the Flexitron selector assembly, the treatment unit functions correctly. Spot checks performed by physics confirmed normal operation of the treatment unit. The treatment unit reentered clinical service the following day and this patient was successfully treated on 11/21/22 for their third fraction and they finished treatment on 11/23/22. Notified: R1DO (Cahill). Notified via email: NMSS Event Notification. 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. |