The following information was received from the
Texas Department of State Health Services (the Agency) via email:
On December 30, 2020, the Agency was notified by the licensee's radiation safety officer (RSO) that a medical event had occurred at their facility. A patient was to receive a single fraction of 700 centigray from a high dose rate remote afterloader unit (HDR) but received a dose of 525 centigray. The patient was notified of the error and the RSO stated they were in the process of notifying the physician. The RSO stated that there would be no adverse effects to the patient from the error. The RSO was unsure of the manufacturer and model of the HDR unit and the activity of the iridium source that was used. Additional information was requested by the Agency. Additional information will be provided as it is received in accordance with SA-300.
Texas Incident No.: 9819