ENS 48678

v t e ENS Event
05:00 Jan 15, 2013
Title	Agreement State Report - Misplacement of Brachytherapy Source During Medical Treatment
Event Description	The following information was provided by the State of Ohio: The Ohio Department of Health Bureau of Radiation Protection was notified by the licensee RSO of a potential medical event. A patient was planned for a vaginal cylinder (HDR) procedure. Approved plan prescribed 4 Gy to target organ (vaginal canal) and 4.61 Gy to rectum. On the first of three fractions, the cylinder was inserted by the Authorized User (AU) in the rectum instead of the vaginal canal. The AU reviewed the film and approved the position for treatment. The physicist determined that the rectum received approximately 6.1 Gy (132% of the prescribed dose). At the time of this report it appears that the intended treatment target received less than 2 Gy (less than 50% of prescribed dose). The device used is a remote afterloader HDR manufactured by Nucletron, Model Microselectron S/N 31472, containing a single sealed source of 4.15 Ci Ir-192. The cause is identified as human error. Item Number: OH130001 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 48678 +/-
Where
Akron General Medical Center Akron, Ohio (NRC Region 3)
License number:	02120-78-0000
Organization:	Ohio Bureau Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+35.77 h1.49 days <br />0.213 weeks <br />0.049 months <br />)
Opened:	Karl Von Ahn 16:46 Jan 16, 2013
NRC Officer:	Steve Sandin
Last Updated:	Jan 16, 2013
48678 - NRC Website
v • d • e

v t e Emergency Notification System
Akron General Medical Center with Agreement State
WEEKMONTHYEAR2017-11-06T05:00:00 [Table view]
[ENS list for Akron General Medical Center]

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