The
VA National Health Physics Program (master materials licensee) reported a possible medical event at one of its permittees involving a
Co-60 teletherapy device. The possible event occurred at the
VA North
Texas Health Care System, Dallas,
Texas, on the dates of April 9 and 10, 2005.
A patient was treated on Saturday and Sunday, April 9 and 10, 2005, for spinal cord compression. The written directive prescribed a dose of 500 cGy in two equal daily fractions. The intent was to give a total dose of about 2900 cGy, with another directive for the remainder of the fractions to be written on April 11, 2005. The treatment time for the fractions on April 9 and 10, 2005, was miscalculated. 330 cGy were administered instead of the prescribed 500 cGy. To avoid too low a dose, an additional fraction of 200 cGy will be given to the patient. This would not have met the definition of a medical event had a single directive, instead of two, been written for the entire treatment series.
No adverse effect to the patient from the event is expected. The permittee has notified the referring physician and patient.
The licensee will notify the NRC Region III Project Manager (
Kevin Null).