Event Notification Report for March 06, 2018
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
03/05/2018 - 03/06/2018
EVENT NUMBERS
53313
Agreement State
Event Number: 53313
Rep Org: SC DIV OF HEALTH & ENV CONTROL
Licensee: MEDICAL UNIVERSITY OF SC
Region: 1
City: CHARLESTON State: SC
County:
License #: SC 081
Agreement: Y
Docket:
NRC Notified By: JIM PETERSON
HQ OPS Officer: BETHANY CECERE
Licensee: MEDICAL UNIVERSITY OF SC
Region: 1
City: CHARLESTON State: SC
County:
License #: SC 081
Agreement: Y
Docket:
NRC Notified By: JIM PETERSON
HQ OPS Officer: BETHANY CECERE
Notification Date: 04/04/2018
Notification Time: 10:10 [ET]
Event Date: 03/06/2018
Event Time: 00:00 [EDT]
Last Update Date: 04/04/2018
Notification Time: 10:10 [ET]
Event Date: 03/06/2018
Event Time: 00:00 [EDT]
Last Update Date: 04/04/2018
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
FRANK ARNER (R1DO)
GRETCHEN RIVERA-CAPELLA (NMSS DAY)
NMSS_EVENTS_NOTIFICATION (EMAIL)
FRANK ARNER (R1DO)
GRETCHEN RIVERA-CAPELLA (NMSS DAY)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - DOSE DELIVERED TO WRONG TREATMENT SITE
A patient was prescribed treatment by High Dose Rate (HDR) brachytherapy to a breast keloid in two fractions on 3/6/18 and 3/7/18 of 600 cGy per fraction. The patient contacted the oncologist when a skin/tissue reaction was discovered on 4/2/18. The reaction was not an anticipated response to the treatment plan.
The fractions were likely directed to the wrong treatment site due to an improper length HDR catheter.
The patient will be evaluated by the oncologist this week.
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.
A patient was prescribed treatment by High Dose Rate (HDR) brachytherapy to a breast keloid in two fractions on 3/6/18 and 3/7/18 of 600 cGy per fraction. The patient contacted the oncologist when a skin/tissue reaction was discovered on 4/2/18. The reaction was not an anticipated response to the treatment plan.
The fractions were likely directed to the wrong treatment site due to an improper length HDR catheter.
The patient will be evaluated by the oncologist this week.
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.