ENS 54728: Difference between revisions
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{{ENS notification | {{ENS notification | ||
| event number = 54728 | | event number = 54728 | ||
| facility = | | facility = | ||
| Organization = Alabama Radiation Control | | Organization = Alabama Radiation Control | ||
| license number = 584 | | license number = 584 | ||
| Line 10: | Line 10: | ||
| utype = | | utype = | ||
| cfr = Agreement State | | cfr = Agreement State | ||
| emergency class = | | emergency class = Non Emergency | ||
| notification date = 05/27/2020 08:06 | | notification date = 05/27/2020 08:06 | ||
| notification by = Cason Coan | | notification by = Cason Coan | ||
| Line 20: | Line 20: | ||
The Alabama Department of Public Health Office of Radiation Control was notified on May 26, 2020, at about 1620 CDT by the Radiation Safety Officer (RSO) of the University of South Alabama Health University Hospital (license 584) of a possible misadministration via HDR [high dose rate] afterloader. The RSO stated that the patient was apparently treated at the wrong treatment site on May 26, 2020 around 1530 CDT; the prescribed dose for the fraction was 700 cGy (treatment course to total 2100 cGy). The licensee is currently working to reconstruct dosimetry at the time of this report, and is unsure of the variance from the prescribed dose. The licensee is authorized to possess an Elekta 136149A02, with a maximum of 12 Ci of Ir-192. | The Alabama Department of Public Health Office of Radiation Control was notified on May 26, 2020, at about 1620 CDT by the Radiation Safety Officer (RSO) of the University of South Alabama Health University Hospital (license 584) of a possible misadministration via HDR [high dose rate] afterloader. The RSO stated that the patient was apparently treated at the wrong treatment site on May 26, 2020 around 1530 CDT; the prescribed dose for the fraction was 700 cGy (treatment course to total 2100 cGy). The licensee is currently working to reconstruct dosimetry at the time of this report, and is unsure of the variance from the prescribed dose. The licensee is authorized to possess an Elekta 136149A02, with a maximum of 12 Ci of Ir-192. | ||
Alabama Incident Report No.: 20-09. | Alabama Incident Report No.: 20-09. | ||
A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. | 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. | ||
| URL = https://www.nrc.gov/reading-rm/doc-collections/event-status/event/2020/20200605en.html#en54728 | | URL = https://www.nrc.gov/reading-rm/doc-collections/event-status/event/2020/20200605en.html#en54728 | ||
}} | }} | ||
{{ENS-Nav}} | {{ENS-Nav}} | ||
Latest revision as of 11:35, 15 January 2021
| Where | |
|---|---|
| Alabama Radiation Control Mobile, Alabama (NRC Region 1) | |
| License number: | 584 |
| Organization: | Alabama Radiation Control |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+11.6 h0.483 days <br />0.069 weeks <br />0.0159 months <br />) | |
| Opened: | Cason Coan 08:06 May 27, 2020 |
| NRC Officer: | Brian Lin |
| Last Updated: | May 27, 2020 |
| 54728 - NRC Website | |