ENS Event | |
|---|---|
04:00 Oct 21, 2016 | |
| Title | Agreement State Report - Medical Misadministration to Incorrect Site |
| Event Description | The following report was received from the State of Georgia via email:
Northside Hospital's Radiation Safety Officer called the Department [Georgia Radioactive Materials Program Environmental Protection Division] on 10/21/2016, informing us of a misadministration with the HDR [High Dose Rate] that occurred approximately two weeks ago. The patient was to receive 5 vaginal treatments consisting of 1 cylinder, 1 capri and 3 capris. The misadministration occurred during the second treatment. The capri was inserted into the rectum instead of the vagina. The Authorized User (AU) was not certain if a misadministration occurred until 2 weeks after the treatment. The AU requested the assistance of the radiologist who confirmed that the rectum was treated instead of the vaginal area. Based on the calculations, the rectum received approximately 350 cGy, what is to be considered a low dose. Additional information from the licensee will be forthcoming. Treatment material used: Varian Medical Systems, model: Gamma Medplus iX, with an Ir-192 source of less than 22 Ci. 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 | |
|---|---|
| Northside Hospital Atlanta, Georgia (NRC Region 1) | |
| License number: | GA 39-1. AMEN |
| Organization: | Georgia Radioactive Material Pgm |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+295.63 h12.318 days <br />1.76 weeks <br />0.405 months <br />) | |
| Opened: | Irene Bennett 11:38 Nov 2, 2016 |
| NRC Officer: | John Shoemaker |
| Last Updated: | Nov 2, 2016 |
| 52341 - NRC Website | |
Northside Hospital with Agreement State | |
WEEKMONTHYEARENS 537742018-12-04T05:00:0004 December 2018 05:00:00
[Table view]Agreement State Agreement State Report - Occupational Exposure Exceeding Regulatory Limits ENS 523412016-10-21T04:00:00021 October 2016 04:00:00 Agreement State Agreement State Report - Medical Misadministration to Incorrect Site 2018-12-04T05:00:00 | |