ENS 54544

v t e ENS Event
18:15 Feb 24, 2020
Title	Agreement State Report - Patient Underdose
Event Description	The following was received from the state of Florida via email: On 24 Feb. 2020, at 1315 EST, an underdose of radiation to a patient receiving skin therapy occurred. The patient was scheduled to receive five fractions, at 7.5 grays per fraction, on five different parts of the left hand per fraction. On the first dose of the first fraction, it was observed that catheter numbers 1 - 15 were reversed, causing an underdose to the patient. No Authorized Users were exposed to the source or otherwise contaminated. The licensee has agreed to submit further information on 26 Feb 2020. Since the cause of this incident is machine generated, in accordance with BRC [State of Florida Bureau of Radiation Control] procedures, it is not being given an incident number, and is being forwarded to ERCX [the X-Ray Machine Section of the BRC]. 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 54544 +/-
Where
Florida Bureau Of Radiation Control Weston, Florida (NRC Region 1)
License number:	3748-2
Organization:	Florida Bureau Of Radiation Control
Reporting

Agreement State
Time - Person (Reporting Time:+23.8 h0.992 days <br />0.142 weeks <br />0.0326 months <br />)
Opened:	Matthew Senison 18:03 Feb 25, 2020
NRC Officer:	Bethany Cecere
Last Updated:	Feb 25, 2020
54544 - 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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