ENS 49310

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v t e ENS Event
05:00 Aug 22, 2013
Title	Agreement State Report - Therapy Dose Applied to Wrong Location
Event Description	The following report was received via e-mail from the Louisiana Department of Environmental Quality: On 08/27/2013, the RSO for Tulane University Hospital called to notify the Department that their facility had a Medical Event involving [exposure to unintended tissue greater than] 50 Rem. The event was discovered on 08/27/2013 when an application was not able to be applied to the intended tissue. The HDR source had 'dog legged' into the bowel area when it was intended to apply the radiation dose to the cervical area. The films were pulled for the application on 08/22/2013 and revealed that the application had 'dog legged' also. The cervical tissue did not receive the initial intended dose. The HDR [High Dose Rate Brachytherapy Afterloader] unit was a Nucletron Micro-Selectron, loaded with [an] Ir-192 [source]. The therapy dose was 8.4 Gray [840 rads] given in fractions. The patient is to receive the entire corrected therapy dose prescribed. This is believed to be (under investigation) a positioning problem and not an equipment malfunction. The patient's physician has been notified. However, the patient was heavily sedated and has not been notified. Updates will be made when additional information is available. Louisiana Report ID: LA-130001 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 49310 +/-
Where
Tulane University Hospital New Orleans, Louisiana (NRC Region 4)
License number:	LA-3325-LO1
Organization:	Louisiana Radiation Protection Div
Reporting

Agreement State
Time - Person (Reporting Time:+133 h5.542 days <br />0.792 weeks <br />0.182 months <br />)
Opened:	Joe Noble 18:00 Aug 27, 2013
NRC Officer:	Bill Huffman
Last Updated:	Aug 27, 2013
49310 - NRC Website
v • d • e

v t e Emergency Notification System
Tulane University Hospital with Agreement State
WEEKMONTHYEAR2013-08-22T05:00:00 [Table view]
[ENS list for Tulane University Hospital]

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ENS Notification