Semantic search
Jump to navigation
Jump to search
| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 55635 | 7 December 2021 15:00:00 | 10 CFR 35.3045(a)(2) | NON-AGREEMENT State Report - Dose Misadministration | The following is a summary of information received via telephonic conversation from the Radiation Safety Officer at Saint Vincent Indianapolis Hospital: At 1000 EST on December 8, the health physicist became aware that on the previous day a patient was treated with the wrong plan parameters. The patient was given a dose on the same organ as the assigned patient on the treatment report with nearly the same prescribed dose. The total dose was 3030 cGy, which is 1 percent higher than the prescribed dose of 3000 cGy that the patient was prescribed. The treatment was completed with no unintended harm to the patient. The second patient was not affected by the error. The event is being reported under 10CFR35.3045(a)(2) for an administration of a dose or dosage to the wrong individual. 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. |