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The following report was received from theThe following report was received from the State of North Carolina via email:</br>A cancer patient undergoing therapeutic radiation treatment for gastric cancer received an exposure to the wrong treatment site. This error occurred using a HDR afterloader device with a radioactive source containing Ir-192. </br>The event occurred after the dosimetrist made an error while correcting a change to dwell position due to catheter migration. The dwell position was mistakenly adjusted out rather than in. Two treatments were made prior to the error being detected. </br>The error resulted in an approximately 4 cm positioning error, which caused the source to stop short of the target so that the total prescribed dose was not delivered. </br>The patient was informed of the event, and received a correct third treatment as well as external beam therapy. </br>Additional information will be provided as it is provided by the licensee.</br>The intended treatment site was a bile duct which was to receive 700 cGy in three (3) fractions. The first two (2) fractions were delivered on 1/5/2012 and 1/12/2012 with the source mispositioned as indicated above. The Regional Inspector for the State of NC is following up.</br>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.necessarily result in harm to the patient.  +
05:00:00, 5 January 2012  +
47,616  +
16:42:00, 23 January 2012  +
05:00:00, 5 January 2012  +
The following report was received from theThe following report was received from the State of North Carolina via email:</br>A cancer patient undergoing therapeutic radiation treatment for gastric cancer received an exposure to the wrong treatment site. This error occurred using a HDR afterloader device with a radioactive source containing Ir-192. </br>The event occurred after the dosimetrist made an error while correcting a change to dwell position due to catheter migration. The dwell position was mistakenly adjusted out rather than in. Two treatments were made prior to the error being detected. </br>The error resulted in an approximately 4 cm positioning error, which caused the source to stop short of the target so that the total prescribed dose was not delivered. </br>The patient was informed of the event, and received a correct third treatment as well as external beam therapy. </br>Additional information will be provided as it is provided by the licensee.</br>The intended treatment site was a bile duct which was to receive 700 cGy in three (3) fractions. The first two (2) fractions were delivered on 1/5/2012 and 1/12/2012 with the source mispositioned as indicated above. The Regional Inspector for the State of NC is following up.</br>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.necessarily result in harm to the patient.  +
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00:00:00, 23 January 2012  +
060-0019-6  +
Modification date"Modification date" is a predefined property that corresponds to the date of the last modification of a subject and is provided by <a rel="nofollow" class="external text" href="https://www.semantic-mediawiki.org/wiki/Help:Special_properties">Semantic MediaWiki</a>.
02:04:58, 2 March 2018  +
16:42:00, 23 January 2012  +
18.488 d (443.7 hours, 2.641 weeks, 0.608 months)  +
05:00:00, 5 January 2012  +
Agreement State Report - Medical Radiation Treatment Exposure to Wrong Treatment Site  +
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