ENS 54397
ENS Event | |
|---|---|
05:00 Nov 19, 2019 | |
| Title | Agreement State Report - Dose Less than Prescribed Delivered to Treatment Site |
| Event Description | The following information was received via E-mail:
On November 20, 2019, the licensee notified the Virginia Office of Radiological Health (ORH) that a medical event occurred as a result of treating a patient using a High Dose Remote Afterloader Unit (HDR). According to the written directive, 18 Gray (Gy) dose to the neck, in three (3) fractions of 6 Gy, was prescribed. On November 19, 2019, the first of the three fractions was delivered. However, the dose was delivered at 91.5 cm instead of the intended 118.1 cm. This resulted in a dose to the treatment site of approximately 0.3 Gy. The report indicated that the error was discovered on November 20, 2019 at 0830 EST after the medical physicist re-measured the guide tube and catheter. It was discovered that the guide tube and catheter were not connected properly and this caused the dose to be delivered at 91.5 cm. The prescribing physician and the patient were notified immediately (at 0915 EST). ORH will review the licensee's written report and determine additional actions to be taken. Virginia Event Report ID No.: VA-19-005 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. |
| Where | |
|---|---|
| University Of Virginia Charlottesville, Virginia (NRC Region 1) | |
| License number: | 540-248-1 |
| Organization: | Virginia Rad Materials Program |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+35.65 h1.485 days <br />0.212 weeks <br />0.0488 months <br />) | |
| Opened: | Asfaw Fenta 16:39 Nov 20, 2019 |
| NRC Officer: | Donald Norwood |
| Last Updated: | Nov 20, 2019 |
| 54397 - NRC Website
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University of Virginia with Agreement State | |
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