ENS 55925

v t e ENS Event
04:00 Jun 3, 2022
Title	HDR Therapy Administered to Wrong Site
Event Description	The following was received from the New York State Department of Health Bureau of Environmental Radiation Protection (the Department, BERP) via email: A New York State licensee informed the Department on June 3 that a patient received a HDR [(High Dose Rate)] therapy to the wrong site. The male patient was diagnosed with Basal Carcinoma of the skin on the left scalp. The patient received a total of 36 Gy over 6 weeks (6 Gy per week). Doses were delivered using a Varian Model Vari-Source XI. The Physician/Authorized User discovered the event and made the initial report to the Department. He indicated he misidentified the treatment site. It seems the error was discovered June 3, 2022. Treatment dates, notification of patient/family and other details regarding this event are not available to BERP yet. The Radiation Safety Officer is conducting an investigation. The Department will follow-up and provide an update. New York Report ID No. NY-22-04 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 55925 +/-
Where
Confidential - A Nys Medical Licensee Confidential- Medical Licensee, New York (NRC Region 1)
License number:	Confidential - A NYS Medical Licensee
Organization:	New York State Dept. Of Health
Reporting

Agreement State
Time - Person (Reporting Time:+13.97 h0.582 days <br />0.0832 weeks <br />0.0191 months <br />)
Opened:	Desmond Gordon 17:58 Jun 3, 2022
NRC Officer:	Ossy Font
Last Updated:	Jun 3, 2022
55925 - NRC Website
v • d • e

v t e Emergency Notification System
Confidential - A Nys Medical Licensee with Agreement State
WEEKMONTHYEAR2022-06-03T04:00:00 [Table view]
[ENS list for Confidential - A Nys Medical Licensee]

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