ENS 43288: Difference between revisions
Jump to navigation
Jump to search
StriderTol (talk | contribs) (Created page by program invented by Mark Hawes) |
StriderTol (talk | contribs) (Created page by program invented by StriderTol) |
||
| Line 16: | Line 16: | ||
| event date = 04/04/2007 CDT | | event date = 04/04/2007 CDT | ||
| last update date = 04/06/2007 | | last update date = 04/06/2007 | ||
| title = Improper Applicator Length Leads | | title = Improper Applicator Length Leads to Wrong Dose | ||
| event text = St. Vincent Hospital, (Green Bay, Wisconsin) notified [the state of Wisconsin] of a medical event by telephone, on April 5, 2007. The medical event occurred on April 4, 2007 and involved an HDR unit. Initial information indicated an incorrect length of catheter was used during the treatment. A [state] inspector was dispatched to the facility on April 6, 2007. | | event text = St. Vincent Hospital, (Green Bay, Wisconsin) notified [the state of Wisconsin] of a medical event by telephone, on April 5, 2007. The medical event occurred on April 4, 2007 and involved an HDR unit. Initial information indicated an incorrect length of catheter was used during the treatment. A [state] inspector was dispatched to the facility on April 6, 2007. | ||
On April 4, 2007, a patient was scheduled for a single-fraction interstitial treatment using a Varian Vari-Source HDR unit containing 6.24 Curies of Iridium-192. The patient was to receive 900 centigray to the vagina. An incorrect applicator length (100 cm) was input into the treatment plan. The actual applicator length was 120 centimeters. The source is believed not to have entered the patient's body during treatment. The authorized user and the patient were notified, and the patient will return for retreatment on April 12. The licensee is performing their own investigation into the event, including a reenactment of the event. | On April 4, 2007, a patient was scheduled for a single-fraction interstitial treatment using a Varian Vari-Source HDR unit containing 6.24 Curies of Iridium-192. The patient was to receive 900 centigray to the vagina. An incorrect applicator length (100 cm) was input into the treatment plan. The actual applicator length was 120 centimeters. The source is believed not to have entered the patient's body during treatment. The authorized user and the patient were notified, and the patient will return for retreatment on April 12. The licensee is performing their own investigation into the event, including a reenactment of the event. | ||
Latest revision as of 22:16, 1 March 2018
| Where | |
|---|---|
| St. Vincent Hospital Green Bay, Wisconsin (NRC Region 3) | |
| Organization: | Wisconsin Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+55.45 h2.31 days <br />0.33 weeks <br />0.076 months <br />) | |
| Opened: | Paul Schmidt 12:27 Apr 6, 2007 |
| NRC Officer: | Pete Snyder |
| Last Updated: | Apr 6, 2007 |
| 43288 - NRC Website | |