ENS Event | |
|---|---|
17:00 Apr 5, 2004 | |
| Title | Medical Event Involving Fractionated Dose Delivery Higher Than Prescribed |
| Event Description | 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. |
| 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 | |
St. Vincent Hospital with 10 CFR 35.3045(a)(1) | |
WEEKMONTHYEARENS 411332004-10-11T06:00:00011 October 2004 06:00:00
[Table view]10 CFR 35.3045(a)(1) Medical Event Involving Fractionated Dose Delivery Less than Prescribed ENS 406432004-04-05T17:00:0005 April 2004 17:00:00 10 CFR 35.3045(a)(1) Medical Event Involving Fractionated Dose Delivery Higher than Prescribed 2004-04-05T17:00:00 | |