ENS 51670

v t e ENS Event
07:00 Nov 9, 2015
Title	Agreement State Report - Medical Event Involving High Dose Rate Therapy
Event Description	The Department [Colorado Department of Public Health and Environment (CDPHE)] received a phone report from the Radiation Safety Officer for Saint Joseph Hospital regarding a medical event involving the HDR [high dose rate therapy]. A patient was scheduled to receive three fractions of HDR treatment in November, 2015. It is believed the second fraction caused the medical event on November 9, 2015. In December, the patient reported to their primary care physician, burns to the leg. The authorized user was notified in December by the patient and/or primary care physician. The authorized medical physicist and radiation safety officer were notified of the event on January 19, 2016 and notified CDPHE on January 20, 2016. The intended dose to the treatment site was 6,000 cGy with all of the intended dose being delivered to the patient's leg. The preliminary cause was an error with the transfer tube-applicator interface, but the licensee is still conducting an internal investigation. The Department is expecting a full report from the licensee within 15 days and preparing for a visit to investigate the event. Colorado Event Report ID No.: CO16-M16-01 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 51670 +/-
Where
Saint Joseph Hospital Denver, Colorado (NRC Region 4)
License number:	CO 038-02
Organization:	Colorado Dept Of Health
Reporting

Agreement State
Time - Person (Reporting Time:+1739.53 h72.48 days <br />10.354 weeks <br />2.383 months <br />)
Opened:	Phillip Peterson 18:32 Jan 20, 2016
NRC Officer:	Howie Crouch
Last Updated:	Jan 20, 2016
51670 - NRC Website
v • d • e

v t e Emergency Notification System
Saint Joseph Hospital with Agreement State
WEEKMONTHYEAR2015-11-09T07:00:00 [Table view]
[ENS list for Saint Joseph Hospital]

Navigation menu