ENS 41592

v t e ENS Event
06:00 Apr 9, 2005
Title	Possible Medical Event
Event Description	The VA National Health Physics Program (master materials licensee) reported a possible medical event at one of its permittees involving a Co-60 teletherapy device. The possible event occurred at the VA North Texas Health Care System, Dallas, Texas, on the dates of April 9 and 10, 2005. A patient was treated on Saturday and Sunday, April 9 and 10, 2005, for spinal cord compression. The written directive prescribed a dose of 500 cGy in two equal daily fractions. The intent was to give a total dose of about 2900 cGy, with another directive for the remainder of the fractions to be written on April 11, 2005. The treatment time for the fractions on April 9 and 10, 2005, was miscalculated. 330 cGy were administered instead of the prescribed 500 cGy. To avoid too low a dose, an additional fraction of 200 cGy will be given to the patient. This would not have met the definition of a medical event had a single directive, instead of two, been written for the entire treatment series. No adverse effect to the patient from the event is expected. The permittee has notified the referring physician and patient. The licensee will notify the NRC Region III Project Manager (Kevin Null).

ENS 41592 +/-
Where
Va National Health Physics Program Dallas, Texas (NRC Region 4)
License number:	03-23856-01VA
Organization:	Va National Health Physics Program
Reporting

10 CFR 35.3045(a)(1)
Time - Person (Reporting Time:+82.3 h3.429 days <br />0.49 weeks <br />0.113 months <br />)
Opened:	Edwin Leidholdt, Phd 16:18 Apr 12, 2005
NRC Officer:	Bill Huffman
Last Updated:	Apr 12, 2005
41592 - NRC Website
v • d • e

v t e Emergency Notification System
Va National Health Physics Program with 10 CFR 35.3045(a)(1)
WEEKMONTHYEAR2009-01-27T08:00:00 [Table view]
[ENS list for Va National Health Physics Program]

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