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 Entered dateEvent description
ENS 425565 May 2006 13:49:00An 80 year old white female undergoing a Mammosite Brachytherapy (Nuclear Tron V2 model 31662) procedure utilizing Ir-192 source received less than 30% of the prescribed dose of 3400 centi-gray (cGy) (accumulated dose). An incorrect figure was entered into the computer causing the source to stay back 6 cm from the intended position and hence dosing an unintended area of approximately 2 cm with 3 times the prescribed dose of 10,000 cGy. The treatment was given 2 times a day for five days from March 31 to April 7, 2006. The patient saw the attending physician for follow-up on May 2, 2006. The physician discovered the patients skin abnormally red. He contacted the Medical Physicist who investigated and discovered the input error. The physician, patient and the patients family were notified. The patient is well and is being treated for erythema. Florida Incident number: FL 06-062