ENS Event | |
|---|---|
06:00 Dec 4, 2023 | |
| Title | Patient Received Less than Prescribed Dose |
| Event Description | The following report was received via email from the Alabama Department of Public Health, Office of Radiation Control (the Office):
The Office was notified of the medical event during a licensee inspection between February 6 to February 8, 2024. The licensee reported that during a patient's 3rd treatment on 12/4/2023, dwell positions in part of the high dose rate (HDR) applicator (2 ovoids) were successfully completed. Dwell positions in another part of the applicator (the tandem) were interrupted due to an obstruction. After repeated checks and attempts, dwell positions in the tandem could not be completed. The patient received 100 cGy of the intended 600 cGy for the third treatment on 12/4/2023. The licensee examined the applicator, and determined that there appeared to be microfractures in the area of the tandem. The licensee has replaced this applicator, and developed precautionary safety procedures to avoid this matter in the future. The licensee noted that the matter appears to be related to the autoclaving process for applicators. The licensee also revised the patient's treatment course, and the patient was successfully treated during 4th and 5th fractions. The licensee used an Elekta Flexitron serial number: FT00306, with an Alpha-Omega model 136147 source, serial number: D85F-2336, 11.86 Ci of Ir-192 on 11/17/2023." Alabama Incident Number: Pending 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 South Alabama Mobile, Alabama (NRC Region 1) | |
| License number: | RML 584 |
| Organization: | Alabama Radiation Control |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+-6854.12 h-285.588 days <br />-40.798 weeks <br />-9.389 months <br />) | |
| Opened: | Cason Coan 15:53 Feb 21, 2023 |
| NRC Officer: | Brian P. Smith |
| Last Updated: | Feb 21, 2024 |
| 56984 - NRC Website | |
University Of South Alabama with Agreement State | |
WEEKMONTHYEARENS 569842023-12-04T06:00:0004 December 2023 06:00:00
[Table view]Agreement State Patient Received Less than Prescribed Dose 2023-12-04T06:00:00 | |