ENS 53932

v t e ENS Event
05:00 Mar 7, 2019
Title	Agreement State Report - Misadministration of Dose to Patient
Event Description	The following was received via e-mail: On March 14, 2019, the Texas Department of Health Services was notified by the licensee's radiation safety officer (RSO) that a therapy event had occurred. A patient was scheduled for three fractions using a high dose rate after loader containing a 6.8 curie iridium-192 source. Multiple catheters were to be used. On March 14, 2019, prior to the third fraction, the licensee determined that one of the catheters was shorter than the length required and the patient received 350 centigrays (50 percent) of the prescribed dose to the thigh resulting in the target tissue receiving 50 percent of the prescribed dose (350 centigrays). The third fraction was not administered. The RSO stated they intended to create a new treatment plan to correct the error and insure the intended area receives the correct dose. Additional information will be provided as it is received in accordance with SA-300. Texas Incident Number: 9665 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.

ENS 53932 +/-
Where
Texas Oncology Pa Austin, Texas (NRC Region 4)
License number:	L05108
Organization:	Texas Dept Of State Health Services
Reporting

Agreement State
Time - Person (Reporting Time:+180.08 h7.503 days <br />1.072 weeks <br />0.247 months <br />)
Opened:	Art Tucker 16:05 Mar 14, 2019
NRC Officer:	Joanna Bridge
Last Updated:	Mar 14, 2019
53932 - NRC Website
v • d • e

v t e Emergency Notification System
Texas Oncology Pa with Agreement State
WEEKMONTHYEAR2019-07-30T05:00:00 [Table view]
[ENS list for Texas Oncology Pa]

Navigation menu