ENS 54548

v t e ENS Event
05:00 Feb 24, 2020
Title	Medical Event - Hdr Underdose to Patient
Event Description	The following information was received from the state of Florida via E-mail: [The licensee] reported to the BRC [Bureau of Radiation Control] on 25 Feb 2020, and e-mailed an incident report on 26 Feb 2020 at 1224 EST that on 24 Feb 2020 at 1315 EST an HDR [high dose rate] incident occurred to a patient receiving skin therapy. The patient was prescribed 7.5 Gray x 5 fractions, on five different parts of the left hand. On the first dose of the first fraction, it was observed that catheter numbers 1 - 15 were reversed, causing an underdose to the patient by 56.25 percent. No Authorized Users were exposed to the source or otherwise contaminated. Florida Incident Number: FL20-022 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.

ENS 54548 +/-
Where
Cleveland Clinic Florida Weston, Florida (NRC Region 1)
License number:	3748-2
Organization:	Florida Bureau Of Radiation Control
Reporting

Agreement State
Time - Person (Reporting Time:+82.9 h3.454 days <br />0.493 weeks <br />0.114 months <br />)
Opened:	Mark Seidensticker 15:54 Feb 27, 2020
NRC Officer:	Donald Norwood
Last Updated:	Feb 27, 2020
54548 - NRC Website
v • d • e

v t e Emergency Notification System
Florida Bureau of Radiation Control with Agreement State
WEEKMONTHYEAR	Agreement State Report - Vehicle Carrying Radio-Pharmaceuticals Involved in Accident	Agreement State Report - Lost/Stolen Troxler Gauge	Agreement State Report - Leaking Sealed Source	2020-09-04T04:00:00 [Table view]
[ENS list for Florida Bureau of Radiation Control]

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