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Event Notification Report for May 08, 2008

U.S. Nuclear Regulatory Commission
Operations Center

EVENT REPORTS FOR
05/07/2008 - 05/08/2008

EVENT NUMBERS
44192

Hospital
Event Number: 44192
Rep Org: BRIDGEPORT HOSPITAL
Licensee: BRIDGEPORT HOSPITAL
Region: 1
City: BRIDGEPORT   State: CT
County:
License #: 06-01060-01
Agreement: N
Docket:
NRC Notified By: DAVID WISHCO
HQ OPS Officer: PETE SNYDER
Notification Date: 05/08/2008
Notification Time: 09:31 [ET]
Event Date: 05/08/2008
Event Time: 00:00 [EDT]
Last Update Date: 05/08/2008
Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
Person (Organization):
ART BURRITT (R1)
MICHELE BURGESS (FSME)
Event Text
BRACHYTHERAPY UNDERDOSE TO 2 PATIENTS

The licensee discovered that 2 patients received underdoses from brachytherapy in January 2008. The underdoses were discovered May 7, 2008. The cause was related to a change in the input made to the treatment planning computer involving the magnification factor. The prescribed doses were 5500 centigray to the cervix of both patients and delivered dose was 2550 centigray. The patient's prescribing physician and oncologist have been informed and discussions are underway to determine future actions. The patients have not yet been informed.

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.