ENS 43145: Difference between revisions
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| event date = 02/04/2007 18:00 EST | | event date = 02/04/2007 18:00 EST | ||
| last update date = 02/06/2007 | | last update date = 02/06/2007 | ||
| title = Medical Event - Patient Received | | title = Medical Event - Patient Received an Underdose | ||
| event text = A FS (Tandem and ovoid) device was loaded into a patient for Cs-137 brachytherapy of the cervix on Friday Feb 2, 2007. The written directive was for 3000 cGy to Pt A in 48.5 hours. Upon removal of the device on Sunday Feb 4, 2007 at approximately 5PM it was observed that the plastic tube used to hold the Cs sources in the tandem was not of the standard length: it was short by approximately 4 cm. The consequence of this would be that the tandem sources would not have been in the position planned. The patient received an underdose to Point A of 760 cGy vs. the 3000 cGy that had been prescribed. Follow-up treatment is planned to correct for this underdose. Clinically, according to the physician, the dose the patient received to distal vaginal would not be expected to cause adverse reactions. " | | event text = A FS (Tandem and ovoid) device was loaded into a patient for Cs-137 brachytherapy of the cervix on Friday Feb 2, 2007. The written directive was for 3000 cGy to Pt A in 48.5 hours. Upon removal of the device on Sunday Feb 4, 2007 at approximately 5PM it was observed that the plastic tube used to hold the Cs sources in the tandem was not of the standard length: it was short by approximately 4 cm. The consequence of this would be that the tandem sources would not have been in the position planned. The patient received an underdose to Point A of 760 cGy vs. the 3000 cGy that had been prescribed. Follow-up treatment is planned to correct for this underdose. Clinically, according to the physician, the dose the patient received to distal vaginal would not be expected to cause adverse reactions. " | ||
* * * UPDATE FROM FLANNERY (FSME) TO HUFFMAN VIA E-MAIL AT 1218 EST ON 2/06/07 * * * | * * * UPDATE FROM FLANNERY (FSME) TO HUFFMAN VIA E-MAIL AT 1218 EST ON 2/06/07 * * * | ||
Latest revision as of 22:17, 1 March 2018
| Where | |
|---|---|
| University Of Virginia Charlottesville, Virginia (NRC Region 1) | |
| License number: | 45-00034-26 |
| Organization: | University Of Virginia Hospital |
| Reporting | |
| 10 CFR 35.3045(a)(1) | |
| Time - Person (Reporting Time:+14.93 h0.622 days <br />0.0889 weeks <br />0.0205 months <br />) | |
| Opened: | Debby Steva 13:56 Feb 5, 2007 |
| NRC Officer: | John Mackinnon |
| Last Updated: | Feb 6, 2007 |
| 43145 - NRC Website
| |