ENS Event | |
|---|---|
20:48 Nov 17, 2011 | |
| Title | Agreement State Report - Patient Received Greater Than The Prescribed Dose |
| Event Description | A patient had a mass surgically removed from both sides of the nose and was undergoing a topical treatment for microscopic disease using a Nucletron HDR containing 8.52 curies of Ir-192 with a Valencia Model H3 skin applicator containing a platinum filter.
The planned administration was 7 fractions of 600 centigrays each on both the left and right side of the nose. During the initial planning for the treatment, an error was made in calculating the dwell time for each location and this incorrect data was entered into the HDR system. As a result of the error, the patient received 54% during each fraction (treatment) during two of the seven fractions on each side of the nose. Prior to the third fraction, the medical team is required per procedure to check calculations and caught the error before the third fraction (treatment) was performed. The patient and prescribing physician have been informed, and there is no long range medical concern for disease as a result of this error. The total dose treatment has not been exceeded. The state's licensee is revising procedures in order to prevent recurrence, and the state will be submitting an NMED report. New Jersey Incident Number: #410674 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 | |
|---|---|
| South Jersey Healthcare Regional Medical Center Vineland, New Jersey (NRC Region 1) | |
| License number: | 450632 |
| Organization: | Nj Rad Prot And Rel Prevention Pgm |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+18.95 h0.79 days <br />0.113 weeks <br />0.026 months <br />) | |
| Opened: | Bill Csaszar 15:45 Nov 18, 2011 |
| NRC Officer: | Joe O'Hara |
| Last Updated: | Nov 18, 2011 |
| 47458 - NRC Website | |
South Jersey Healthcare Regional Medical Center with Agreement State | |
WEEKMONTHYEARENS 474582011-11-17T20:48:00017 November 2011 20:48:00
[Table view]Agreement State Agreement State Report - Patient Received Greater than the Prescribed Dose 2011-11-17T20:48:00 | |