ENS 40643: Difference between revisions
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| event date = 04/05/2004 11:00 CST | | event date = 04/05/2004 11:00 CST | ||
| last update date = 04/05/2004 | | last update date = 04/05/2004 | ||
| title = Medical Event Involving Fractionated Dose Delivery Higher | | title = Medical Event Involving Fractionated Dose Delivery Higher than Prescribed | ||
| event text = A patient was prescribed five (5) fractional treatments of 500 centigray each to the surface using a 6.7 curie Ir-192 brachytherapy source. On 3/15, 3/22 and 3/29/04 the patient received 500 centigray/fraction at a depth of 5 mm. This resulted in a delivered dose of 818 centigray/fraction at the surface. The error was discovered prior to delivering the fourth (4th) fraction and is attributed to a miscalculation. The prescribing physician has been informed and concluded that there would be no adverse effects to the patient. The licensee is implementing additional reviews to preclude this type of event from reoccurring. | | event text = A patient was prescribed five (5) fractional treatments of 500 centigray each to the surface using a 6.7 curie Ir-192 brachytherapy source. On 3/15, 3/22 and 3/29/04 the patient received 500 centigray/fraction at a depth of 5 mm. This resulted in a delivered dose of 818 centigray/fraction at the surface. The error was discovered prior to delivering the fourth (4th) fraction and is attributed to a miscalculation. The prescribing physician has been informed and concluded that there would be no adverse effects to the patient. The licensee is implementing additional reviews to preclude this type of event from reoccurring. | ||
| URL = http://www.nrc.gov/reading-rm/doc-collections/event-status/event/2004/20040406en.html#en40643 | | URL = http://www.nrc.gov/reading-rm/doc-collections/event-status/event/2004/20040406en.html#en40643 | ||
Latest revision as of 22:23, 1 March 2018
| Where | |
|---|---|
| St. Vincent Hospital Indianpolis, Indiana (NRC Region 3) | |
| License number: | 13-00133-02 |
| Organization: | St. Vincent Hospital |
| Reporting | |
| 10 CFR 35.3045(a)(1) | |
| Time - Person (Reporting Time:+-0.45 h-0.0188 days <br />-0.00268 weeks <br />-6.1641e-4 months <br />) | |
| Opened: | Ed Wroblewski 16:33 Apr 5, 2004 |
| NRC Officer: | Steve Sandin |
| Last Updated: | Apr 5, 2004 |
| 40643 - NRC Website | |