ENS Event | |
|---|---|
17:00 Jan 17, 2005 | |
| Title | Medical Misadministration - Wrong Treatment Site |
| Event Description | The State provided the following NMED information:
On 1/18/05, the licensee reported to the Agency a teletherapy misadministration that occurred on 1/17/05. The situation was described as 'the treatment field was displaced by six cm when the therapist set the central axis of the field at the tattoo marking the bottom of the field'. An area of 15 cm x 6 cm (treatment site) received dose when the plan called for that tissue to receive no dose. The dose was one day's treatment of 180 cGy. The treatment monitor units and energy were correct, the error was entirely an issue of field placement. The Regulation Code cited is 105 CFR 120.502 (4) (a). The intended dose to the patient was 180 cGy, however, only 90 cGy was given to the wrong treatment site (15 cm x 6 cm area). Per the treating physician, no corrective action is needed. The hospital retrained staff to ensure confirming proper positioning of therapy prior to treatment. Event type Description: MD2 - Wrong Treatment Site. Cause description: The therapist did not correctly align the treatment field with the patient's treatment alignment tattoo. The Agency considers this event closed.
The following information was provided by the State via facsimile (State text in quotes): The device used to deliver the radiation treatment was a LINEAR ACCELERATOR. Notified R1 DO (Noggle) and NMSS EO (T. Essig)
Based on a discussion with the NMSS EO (T. Essig) and the State (T. Carpenito), this notification is retracted because the device used to deliver the radiation treatment is not regulated by NRC. Notified R1 DO (Noggle) and NMSS EO (T. Essig) |
| Where | |
|---|---|
| Lowell General Hospital Lowell, Massachusetts (NRC Region 1) | |
| License number: | 44-0060 |
| Organization: | Ma Radiation Control Program |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+1699.77 h70.824 days <br />10.118 weeks <br />2.328 months <br />) | |
| Opened: | Tony Carpenito 12:46 Mar 29, 2005 |
| NRC Officer: | John Knoke |
| Last Updated: | Apr 4, 2005 |
| 41542 - NRC Website | |
Lowell General Hospital with Agreement State | |
WEEKMONTHYEARENS 468552011-02-16T04:00:00016 February 2011 04:00:00
[Table view]Agreement State Agreement State Report - Dose to Fetus During Thyroid Scan ENS 415422005-01-17T17:00:00017 January 2005 17:00:00 Agreement State Medical Misadministration - Wrong Treatment Site 2011-02-16T04:00:00 | |