ENS Event | |
|---|---|
05:00 Feb 25, 2025 | |
| Title | Medical Event |
| Event Description | The following is a summary of information provided by the State of Florida, Bureau of Radiation Control (the BRC) via email:
[BRC was notified of a medical event involving a high dose rate (HDR) prostate treatment that] occurred on 2/25/25, was identified during the weekend of 3/1/25 to 3/2/25, and was determined to have been a medical event by the facility on 3/3/25. During [delivery of] the second fraction of two fractions, Comprehensive Hematology Oncology incorrectly typed the catheter length into the procedure's software. This resulted in the dose being received 5 cm short of the intended location. The prostate received no dose during this fraction, and the rectum received an estimated 60 percent of its expected dose. The patient and primary physician have been notified. The second fraction has been rescheduled. The following additional information was obtained from the licensee in accordance with Headquarters Operations Officers Report Guidance: The prescribed dose for the second fraction of the HDR prostate treatment was unknown at the time of the notification. This event is similar but involved a different patient than EN 57581 (FL25-019). Florida Incident Number: FL25-018
Current information, retrieved by BRC, states that the intended total dose was 2700 cGy delivered over two fractions. 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 | |
|---|---|
| Comprehensive Hematology Oncology Trinity, Florida (NRC Region 1) | |
| License number: | 4657-3 |
| Organization: | Florida Bureau Of Radiation Control |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+151.62 h6.318 days <br />0.902 weeks <br />0.208 months <br />) | |
| Opened: | Monroe A. Cooper 12:37 Mar 3, 2025 |
| NRC Officer: | Ernest West |
| Last Updated: | Mar 4, 2025 |
| 57580 - NRC Website | |
Comprehensive Hematology Oncology with Agreement State | |
WEEKMONTHYEARENS 575812025-02-25T05:00:00025 February 2025 05:00:00
[Table view]Agreement State Medical Event ENS 575802025-02-25T05:00:00025 February 2025 05:00:00 Agreement State Medical Event 2025-02-25T05:00:00 | |