ENS 49770

v t e ENS Event
05:00 Jan 24, 2014
Title	Agreeement State Report - Patient Received Less than Prescribed Dose
Event Description	The following was received from the State of Ohio via email: On Jan. 27, 2014, the RSO of Flower Hospital provided a telephone report of medical event that occurred on Jan. 24 and 27, 2014. A patient was being treated with a Varian GammaMed Plus HDR with 4.7 Ci of lr-192 in a vaginal cylinder. The written directive was for three fractions of 500 cGy for a total of 1,500 cGy. Then during the delivery of the second fraction the licensee realized that they were only delivering a planned dose of 166 cGy. The licensee completed the second fraction as planned. The treatment planning was entered as one third of the 500 cGy for three fractions instead of three fractions of 500 cGy. The license will modify the treatment plan to give the full prescribed 1500 cGy to the patient. The patient was notified on Jan. 27, 2014. This is a reportable medical event under OAC 3701:1-58-101 (A)(1)(c.) for a fractionated dose that differs by more than 50%. Ohio Report #: OH140001 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 49770 +/-
Where
Flower Hospital Sylvania, Ohio (NRC Region 3)
License number:	02120 49 0004
Organization:	Ohio Bureau Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+84.08 h3.503 days <br />0.5 weeks <br />0.115 months <br />)
Opened:	Karl Von Ahn 17:05 Jan 27, 2014
NRC Officer:	Charles Teal
Last Updated:	Jan 27, 2014
49770 - NRC Website
v • d • e

v t e Emergency Notification System
Flower Hospital with Agreement State
WEEKMONTHYEAR2016-05-31T04:00:00 [Table view]
[ENS list for Flower Hospital]

Navigation menu