ENS Event | |
|---|---|
20:30 May 26, 2020 | |
| Title | Agreement State Report - Possible Administration at the Wrong Treatment Site |
| Event Description | The following information was received from the state of Alabama via email:
The Alabama Department of Public Health Office of Radiation Control was notified on May 26, 2020, at about 1620 CDT by the Radiation Safety Officer (RSO) of the University of South Alabama Health University Hospital (license 584) of a possible misadministration via HDR [high dose rate] afterloader. The RSO stated that the patient was apparently treated at the wrong treatment site on May 26, 2020 around 1530 CDT; the prescribed dose for the fraction was 700 cGy (treatment course to total 2100 cGy). The licensee is currently working to reconstruct dosimetry at the time of this report, and is unsure of the variance from the prescribed dose. The licensee is authorized to possess an Elekta 136149A02, with a maximum of 12 Ci of Ir-192. Alabama Incident Report No.: 20-09. 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 | |
|---|---|
| Usa Health University Hospital Mobile, Alabama (NRC Region 1) | |
| License number: | 584 |
| Organization: | Alabama Radiation Control |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+11.6 h0.483 days <br />0.069 weeks <br />0.0159 months <br />) | |
| Opened: | Cason Coan 08:06 May 27, 2020 |
| NRC Officer: | Brian Lin |
| Last Updated: | May 27, 2020 |
| 54728 - NRC Website | |
Alabama Office of Radiation Control with Agreement State | |
WEEKMONTHYEARENS 548422020-08-14T05:00:00014 August 2020 05:00:00
[Table view]Agreement State Agreement State Report - Lost Source ENS 548132020-08-03T22:00:0003 August 2020 22:00:00 Agreement State Agreement State Report - Damaged Radiography Camera ENS 547282020-05-26T20:30:00026 May 2020 20:30:00 Agreement State Agreement State Report - Possible Administration at the Wrong Treatment Site ENS 547152020-05-14T05:00:00014 May 2020 05:00:00 Agreement State Agreement State Report - Broken Shutter Handle ENS 545772020-03-07T06:00:0007 March 2020 06:00:00 Agreement State Agreement State Report -- Broken Radiography Camera in Shielded Position ENS 544832020-01-16T20:45:00016 January 2020 20:45:00 Agreement State Alabama Agreement State Report - Patient Received Greater Dose than Prescribed ENS 513462015-08-25T05:00:00025 August 2015 05:00:00 Agreement State Abandoned Gauge Found in Scrap Metal ENS 455162009-11-17T06:00:00017 November 2009 06:00:00 Agreement State Agreement State Report - Report of Found Cs-137 Source 2020-08-03T22:00:00 | |