ENS 43639

v t e ENS Event
05:00 Feb 1, 2005
Title	Agreement State Report - Dose Differs by Greater than 50% of Prescribed
Event Description	The State provided the following information via email: A teletherapy patient received a dose greater than 50% of the prescribed fractionated dose due to an improperly calculated dose delivery time. The medical physicist used a fractionated dose of 200 cGy instead of the prescribed dose of 100 cGy. This overexposure occurred during the first fraction to the patient. Before the second scheduled treatment, a different therapist questioned the long treatment time and brought the matter to the medical physicist. The physicist checked the calculations, discovered the error and cancelled the treatment for the day. The radiation oncologist anticipates no unusual acute or late effects from the delivered dose. The University of Iowa no longer is in possession of this device. It was de-sourced on November 16, 2005. The device was a sealed Co-60 teletherapy source. The therapy was targeting the bone marrow. Iowa report number: IA070003

ENS 43639 +/-
Where
University Of Iowa Iowa City, Iowa (NRC Region 3)
License number:	0037152AAB
Organization:	Iowa Department Of Public Health
Reporting

Agreement State
Time - Person (Reporting Time:+22907.07 h954.461 days <br />136.352 weeks <br />31.378 months <br />)
Opened:	Randal Dahlin 15:04 Sep 13, 2007
NRC Officer:	Jason Kozal
Last Updated:	Sep 13, 2007
43639 - NRC Website
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University of Iowa with Agreement State
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