ENS Event | |
|---|---|
04:00 Mar 5, 2007 | |
| Title | Agreement State - Medical Event Related To Dose Less Than 20% Prescribed |
| Event Description | Upon quality review a misadministration was discovered by hospital staff on March 3, 2007; the actual medical procedure was performed on January 23, 2007. It is estimated that patient was administered a dose less than 20% of the intended dose. State was notified on 19 March 2007. This incident is referred to [the State's] radioactive materials [office] for investigation.
The misadministration involved a Gamma Knife. A quality review by the licensee confirmed that a treatment dose was prescribed as - 40% of maximum dose equivalent equals 11Gy; but was calculated as - 50% of maximum dose equals 11Gy. This discrepancy resulted in the administration of a dose that was 20% less than intended. State Report FL07-046
This event has been reviewed and determined to be a medical event. Immediate release to the public is authorized. 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 | |
|---|---|
| Doctors Hospital, Inc Coral Gables, Florida (NRC Region 1) | |
| License number: | 3823-2 |
| Organization: | Florida Bureau Of Radiation Control |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+367.95 h15.331 days <br />2.19 weeks <br />0.504 months <br />) | |
| Opened: | Steve Furnace 10:57 Mar 20, 2007 |
| NRC Officer: | Jeff Rotton |
| Last Updated: | Mar 20, 2007 |
| 43252 - NRC Website | |
Doctors Hospital, Inc with Agreement State | |
WEEKMONTHYEARENS 432522007-03-05T04:00:0005 March 2007 04:00:00
[Table view]Agreement State Agreement State - Medical Event Related to Dose Less than 20% Prescribed 2007-03-05T04:00:00 | |