ENS 44321

v t e ENS Event
07:00 Jun 23, 2008
Title	Potential Underdose to Patient Undergoing Whole Body Radiation
Event Description	The following report was received from the state via e-mail: On June 25, 2008 at approximately 3 pm, RHB received preliminary notification of a medical event, which occurred June 23, 2008, involving a 50% under-dose to a patient undergoing whole-body irradiation with a Co-60 teletherapy unit. The event was discovered at approximately 2 pm on June 25, 2008. RHB held the initial report to NRC until additional details could be provided by the licensee, who was still reviewing the situation with the radiation oncology department. The prescription was for total body irradiation at 17.12 minutes AP (anterior posterior), then 17.13 minutes AP, then 17.12 minutes PA (posterior anterior), then 17.13 minutes PA, for a total of 34.25 minutes AP and 34.25 minutes PA, and a total of 300 cGy. The therapist only treated 17.13 minutes AP and 17.13 minutes PA for a total dose of 150 cGy. The patient was seen by the attending physician on 6/25/08, with no known medical effects observed. There is currently no plan to re-treat the patient per the attending physician. The licensee is following up with a written report. 5010 Number - 062508 The attending physician and patient have been notified. 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 44321 +/-
Where
Ucla Westwood, California (NRC Region 4)
License number:	1335-19
Organization:	California Radiation Control Prgm
Reporting

Agreement State
Time - Person (Reporting Time:+100.55 h4.19 days <br />0.599 weeks <br />0.138 months <br />)
Opened:	Barbara Hamrick 11:33 Jun 27, 2008
NRC Officer:	Pete Snyder
Last Updated:	Jun 27, 2008
44321 - NRC Website
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