ENS Event | |
|---|---|
04:00 Mar 6, 2018 | |
| Title | Agreement State Report - Dose Delivered to Wrong Treatment Site |
| Event Description | A patient was prescribed treatment by High Dose Rate (HDR) brachytherapy to a breast keloid in two fractions on 3/6/18 and 3/7/18 of 600 cGy per fraction. The patient contacted the oncologist when a skin/tissue reaction was discovered on 4/2/18. The reaction was not an anticipated response to the treatment plan.
The fractions were likely directed to the wrong treatment site due to an improper length HDR catheter. The patient will be evaluated by the oncologist this week. 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 | |
|---|---|
| Medical University Of Sc Charleston, South Carolina (NRC Region 1) | |
| License number: | SC 081 |
| Organization: | Sc Div Of Health & Env Control |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+703.17 h29.299 days <br />4.186 weeks <br />0.963 months <br />) | |
| Opened: | Jim Peterson 10:10 Apr 4, 2018 |
| NRC Officer: | Bethany Cecere |
| Last Updated: | Apr 4, 2018 |
| 53313 - NRC Website | |
Medical University Of Sc with Agreement State | |
WEEKMONTHYEARENS 533132018-03-06T04:00:0006 March 2018 04:00:00
[Table view]Agreement State Agreement State Report - Dose Delivered to Wrong Treatment Site 2018-03-06T04:00:00 | |