ENS Event | |
|---|---|
04:00 Jul 17, 2015 | |
| Title | Agreement State Report - Medical Overdose for Skin Cancer |
| Event Description | The following report was received via e-mail:
1. A patient received an [Ir-192] HDR treatment using a skin applicator on the nose. This treatment is used to treat skin cancer. 2. The physician's written directive specified a dose to the tumor volume, and a maximum tumor dose of 130 percent of the prescribed dose. The total dose was delivered in 8 fractions. 3. The patient's course of treatment proceeded to conclusion. On recent follow-up exam, the patient's skin reaction was more than usual for this type of treatment, so the physician asked physics to review the plan. 4. This review indicated the tumor volume maximum dose exceeded the prescribed 130 percent by more than 50 percent. The date, time, and dose prescribed/received were not given in the report. 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 | |
|---|---|
| Radiotherapy Clinics Of Georgia Lawrenceville, Georgia (NRC Region 1) | |
| Organization: | Georgia Radioactive Material Pgm |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+131.33 h5.472 days <br />0.782 weeks <br />0.18 months <br />) | |
| Opened: | Travis Cartoski 15:20 Jul 22, 2015 |
| NRC Officer: | Mark Abramovitz |
| Last Updated: | Jul 22, 2015 |
| 51251 - NRC Website | |
Radiotherapy Clinics Of Georgia with Agreement State | |
WEEKMONTHYEARENS 512512015-07-17T04:00:00017 July 2015 04:00:00
[Table view]Agreement State Agreement State Report - Medical Overdose for Skin Cancer ENS 512522015-07-01T04:00:0001 July 2015 04:00:00 Agreement State Agreement State Report - Vaginal Catheter Slipped During Treatment ENS 496432013-12-16T05:00:00016 December 2013 05:00:00 Agreement State Agreement State Report - Possible Medical Misadministration 2015-07-17T04:00:00 | |