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| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 46602 | 8 February 2011 05:00:00 | Agreement State | Agreement State Report - Under Dose Received During Brachytherapy Procedure | The following information was received from the State of North Carolina via email: A patient undergoing a HDR (High Dose Rate) brachytherapy procedure received an under dose on three fractions. The guide tubes were misaligned which resulted in a 5 cm displacement from the source plan. This misalignment resulted in a 59% difference in dose (under dose) to the intended site and an overexposure to other tissue. The patient has received three of ten exposures and the plan will be re-worked to mitigate the under dosage of the intended site. The patient has been notified and they are trying to contact the prescribing physician to notify him. An investigation has been initiated to determine the cause of this event and 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. |