ENS 41925
ENS Event | |
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18:30 Aug 4, 2005 | |
Title | Agreement State Report - Medical Event |
Event Description | The State provided the following information via facsimile:
This event involved an HDR brachytherapy unit [Nucletron Corporation Model 105.999, serial number 31062; with sealed source Nucletron Corporation Model 105.002, serial number D36A-7277]. The maximum activity that can be utilized in the unit is 444 gigabecquerels (12 Curies) of Ir-192. The male patient was receiving palliative treatment for metastatic disease. On August 4, 2005, the patient received the second of the three prescribed treatments to the left bronchus. The licensee's Medical Physicist discovered the error on August 10, 2005. The error was a contiguous shift lengthwise of 3 centimeters from the area that was being treated. The intended fraction was 7 Gray. The patient and the referring physician were notified on August 11, 2005. The licensee is still in the process of evaluating the event. The licensee is to submit a written report to the Utah Division of Radiation Control. The treating physician determined that there will be no adverse affect to the patient as a result of this event and that diseased tissue may have been treated. The Division of Radiation Control is still investigating this event. Event Report ID Number: UT-05-0006 |
Where | |
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University Of Utah Salt Lake City, Utah (NRC Region 4) | |
License number: | UT 1800001 |
Organization: | Utah Division Of Radiation Control |
Reporting | |
Agreement State | |
Time - Person (Reporting Time:+312.45 h13.019 days <br />1.86 weeks <br />0.428 months <br />) | |
Opened: | Julie Felice 18:57 Aug 17, 2005 |
NRC Officer: | Bill Gott |
Last Updated: | Aug 17, 2005 |
41925 - NRC Website
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University of Utah with Agreement State | |
WEEKMONTHYEARENS 564662023-04-04T18:00:0004 April 2023 18:00:00
[Table view]Agreement State Leaking Source ENS 554822021-09-09T18:00:0009 September 2021 18:00:00 Agreement State Loss of Control of Radioactive Material ENS 526732017-04-10T06:00:00010 April 2017 06:00:00 Agreement State Agreement State Report - Leaking Tritium Exit Sign ENS 517142016-02-02T07:00:0002 February 2016 07:00:00 Agreement State Lost Tritium Exit Sign ENS 421212005-11-05T19:50:0005 November 2005 19:50:00 Agreement State Agreement State - Missing Am-241 Source ENS 419252005-08-04T18:30:0004 August 2005 18:30:00 Agreement State Agreement State Report - Medical Event 2023-04-04T18:00:00 | |