ENS 54775: Difference between revisions
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{{ENS notification | {{ENS notification | ||
| event number = 54775 | | event number = 54775 | ||
| facility = | | facility = | ||
| Organization = California Radiation Control Prgm | | Organization = California Radiation Control Prgm | ||
| license number = 1335-19 | | license number = 1335-19 | ||
| Line 10: | Line 10: | ||
| utype = | | utype = | ||
| cfr = Agreement State | | cfr = Agreement State | ||
| emergency class = | | emergency class = Non Emergency | ||
| notification date = 07/10/2020 20:18 | | notification date = 07/10/2020 20:18 | ||
| notification by = Andrew Taylor | | notification by = Andrew Taylor | ||
| Line 18: | Line 18: | ||
| title = Agreement State Report - Medical Event | | title = Agreement State Report - Medical Event | ||
| event text = The following report was received from the State of California via email: | | event text = The following report was received from the State of California via email: | ||
On July 10, 2020, the Radiation Safety Officer for the University of California, Los Angeles, notified the Radiologic Health Branch of a Medical Event that occurred with a Varian High Dose Afterloader with an Ir-192 source during an ovarian cancer treatment. | On July 10, 2020, the Radiation Safety Officer for the University of California, Los Angeles, notified the Radiologic Health Branch of a Medical Event that occurred with a Varian High Dose Afterloader with an Ir-192 source during an ovarian cancer treatment. The prescribed dose to the intended organ was 24 Gray (2400 rad). Due to an incorrect entry of the catheter length into the treatment delivery system, an unintended dose of 21.8 Gray (2180 rad) was estimated to have been delivered to the large bowel. The dose delivered to the intended organ was initially estimated at 0 Gray (0 rad). The patient and the patient's physician were notified. The licensee's investigation into this medical event is ongoing and will be reviewed further by the California Department of Public Health | ||
California 5010 report no: 071020 | California 5010 report no: 071020 | ||
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/ | | URL = https://www.nrc.gov/reading-rm/doc-collections/event-status/event/2020/20200721en.html#en54775 | ||
}} | }} | ||
{{ENS-Nav}} | {{ENS-Nav}} | ||
Latest revision as of 11:31, 15 January 2021
| Where | |
|---|---|
| California Radiation Control Prgm Los Angeles, California (NRC Region 4) | |
| License number: | 1335-19 |
| Organization: | California Radiation Control Prgm |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+61.3 h2.554 days <br />0.365 weeks <br />0.084 months <br />) | |
| Opened: | Andrew Taylor 20:18 Jul 10, 2020 |
| NRC Officer: | Solomon Sahle |
| Last Updated: | Jul 10, 2020 |
| 54775 - NRC Website | |