ENS 54023

v t e ENS Event
07:00 Apr 22, 2019
Title	California Agreement State Report - Potential Medical Event
Event Description	The following information was excerpted from a report received from the state of California via email: [A] potential medical event occurred during an HDR [high dose rate] brachytherapy procedure in which the Tandem Ovoid [was] inserted into the patient. The patient was there to receive the 3rd dose of 8 Gy (for a total of 24 Gy) to the uterus. Instead, because all of the guide tubes were 132 cm instead of 120 cm in length, the entire 8 Gy of this last fraction was delivered to the vagina. They do not believe that the uterus received any of the prescribed 8 Gy, and all of it was delivered to non-target organ. The patient and her treating physician were informed, and she is going to return to the hospital for monitoring. Since this was the last of 3 fractions, the uterus has only received 16 Gy, not 24, while the unplanned dose to non-target organ was 8 Gy. A site visit will be conducted Monday, 4/29/2019, [by the California Department of Public Health, Radiologic Health Branch]. CA 5010 Number: 042319 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 54023 +/-
Where
University Of Southern California Medical Center Los Angeles, California (NRC Region 4)
License number:	0134-19
Organization:	California Radiation Control Prgm
Reporting

Agreement State
Time - Person (Reporting Time:+37.53 h1.564 days <br />0.223 weeks <br />0.0514 months <br />)
Opened:	Geza Miko 20:32 Apr 23, 2019
NRC Officer:	Howie Crouch
Last Updated:	Apr 23, 2019
54023 - NRC Website
v • d • e

v t e Emergency Notification System
University Of Southern California Medical Center with Agreement State
WEEKMONTHYEAR2019-04-22T07:00:00 [Table view]
[ENS list for University Of Southern California Medical Center]

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