ENS 53902

v t e ENS Event
08:00 Feb 25, 2019
Title	Agreement State Report - Unintended Dose to Non-Target Tissue
Event Description	The following was received from the state of California: The licensee reported an unintended dose to non-target tissue of a patient from an HDR [High Dose Rate] treatment, apparently due to mispositioning of the uterus-ovary applicator. The unintended dose occurred on the final of four fractions. The target tissue received the intended dose in each of the four fractions, but non-target tissue of the bowel received in excess of 50 rem and 150 percent of the expected dose to the non-target bowel tissue from the four fractions combined, with the excess non-target bowel dose occurring in the final fraction due to the mispositioned applicator. The licensee will submit a 15-day written report to the California Department of Public Health-Radiologic Health Branch (CDPH-RHB) in accordance with 10 CFR 35.3045(d), and will include the calculated dose to the non-target tissue of concern. That report will be forwarded to NRC by CDPH-RHB. The referring physician was informed of the unintended dose to the non-target bowel tissue. CA 5010 Number: 022719 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.

ENS 53902 +/-
Where
Kaiser Permanente Los Angeles, California (NRC Region 4)
License number:	0372
Organization:	California Radiation Control Prgm
Reporting

Agreement State
Time - Person (Reporting Time:+84.85 h3.535 days <br />0.505 weeks <br />0.116 months <br />)
Opened:	Robert Greger 20:51 Feb 28, 2019
NRC Officer:	Jeff Herrera
Last Updated:	Feb 28, 2019
53902 - NRC Website
v • d • e

v t e Emergency Notification System
Kaiser Permanente with Agreement State
WEEKMONTHYEAR2019-02-25T08:00:00 [Table view]
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