ENS 45695: Difference between revisions
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| event date = 02/10/2010 EST | | event date = 02/10/2010 EST | ||
| last update date = 03/23/2010 | | last update date = 03/23/2010 | ||
| title = Agreement State Report - Potential Medical Event Due | | title = Agreement State Report - Potential Medical Event Due to Underdose Greater than 50% | ||
| event text = The following was received from the Commonwealth of Massachusetts via e-mail: | | event text = The following was received from the Commonwealth of Massachusetts via e-mail: | ||
On 2/12/10, licensee reported to this Agency [Commonwealth of Massachusetts] the 2/11/10 discovery of a medical event that occurred on 2/10/10. The situation [was] described as two treatment fraction underdoses, delivered on the same day to the same patient, that differed from the prescribed dose, per fraction, by more than 50%. Initial indication [is] that [the] event was caused by [an] equipment software bug. Two fractions of 0.4 Gy were delivered on the first day of treatment. The prescription was for two treatments of 4 Gy per fraction per day for two days and one final 4 Gy treatment on the third day. [The] prescribing physician and equipment manufacturer [were] notified. This is a preliminary report; investigation [is] ongoing; more information to follow. | On 2/12/10, licensee reported to this Agency [Commonwealth of Massachusetts] the 2/11/10 discovery of a medical event that occurred on 2/10/10. The situation [was] described as two treatment fraction underdoses, delivered on the same day to the same patient, that differed from the prescribed dose, per fraction, by more than 50%. Initial indication [is] that [the] event was caused by [an] equipment software bug. Two fractions of 0.4 Gy were delivered on the first day of treatment. The prescription was for two treatments of 4 Gy per fraction per day for two days and one final 4 Gy treatment on the third day. [The] prescribing physician and equipment manufacturer [were] notified. This is a preliminary report; investigation [is] ongoing; more information to follow. | ||
Latest revision as of 21:10, 1 March 2018
| Where | |
|---|---|
| Mass General Hospital Boston, Massachusetts (NRC Region 1) | |
| License number: | 60-0055 |
| Organization: | Ma Radiation Control Program |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+53.75 h2.24 days <br />0.32 weeks <br />0.0736 months <br />) | |
| Opened: | Tony Carpenito 10:45 Feb 12, 2010 |
| NRC Officer: | Joe O'Hara |
| Last Updated: | Mar 23, 2010 |
| 45695 - NRC Website | |