Event Notification Report for May 21, 2019
U.S. Nuclear Regulatory Commission
Operations Center
EVENT REPORTS FOR
05/20/2019 - 05/21/2019
EVENT NUMBERS
54082
Agreement State
Event Number: 54082
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL
Licensee: FLORIDA CANCER SPECIALISTS - NEW PORT RICHEY
Region: 1
City: NEW PORT RICHEY State: FL
County:
License #: 3825-13
Agreement: Y
Docket:
NRC Notified By: MATTHEW SENISON
HQ OPS Officer: HOWIE CROUCH
Licensee: FLORIDA CANCER SPECIALISTS - NEW PORT RICHEY
Region: 1
City: NEW PORT RICHEY State: FL
County:
License #: 3825-13
Agreement: Y
Docket:
NRC Notified By: MATTHEW SENISON
HQ OPS Officer: HOWIE CROUCH
Notification Date: 05/23/2019
Notification Time: 16:55 [ET]
Event Date: 05/21/2019
Event Time: 00:00 [EDT]
Last Update Date: 05/23/2019
Notification Time: 16:55 [ET]
Event Date: 05/21/2019
Event Time: 00:00 [EDT]
Last Update Date: 05/23/2019
Emergency Class: NON EMERGENCY
10 CFR Section:
AGREEMENT STATE
10 CFR Section:
AGREEMENT STATE
Person (Organization):
FRANK ARNER (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
FRANK ARNER (R1DO)
NMSS_EVENTS_NOTIFICATION (EMAIL)
AGREEMENT STATE REPORT - ACTUAL DOSE GREATER THAN PRESCRIBED DOSE BY 87.6%
The following information was obtained from the state of Florida via email:
"On May 22, 2019, [the licensee Radiation Safety Officer] notified the BRC [Florida Bureau of Radiation Control] of an overdose of radiation treatment to a female 60 year-old Caucasian patient. Patient was prescribed ten 340 cGy planning target volume (ptv) fractionated treatments: 2 per day for 5 days. Minimum dose of 340 cGy per fraction, mean dose value 625 cGy per fraction, actual dose administered 1167.3 cGy in single fraction. Source S/N: 24-01-7403-001-032119-13092-68. Licensee has notified the patient that an overdose did occur, and expects no harm to the patient due to this fraction of treatment. Patient has five more treatments."
The machine used was a Varying GammaMed+, SN 641053, using a 7.385 Ci Iridium-192 GammaMed 232 source.
Florida Incident number: FL19-071
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.
The following information was obtained from the state of Florida via email:
"On May 22, 2019, [the licensee Radiation Safety Officer] notified the BRC [Florida Bureau of Radiation Control] of an overdose of radiation treatment to a female 60 year-old Caucasian patient. Patient was prescribed ten 340 cGy planning target volume (ptv) fractionated treatments: 2 per day for 5 days. Minimum dose of 340 cGy per fraction, mean dose value 625 cGy per fraction, actual dose administered 1167.3 cGy in single fraction. Source S/N: 24-01-7403-001-032119-13092-68. Licensee has notified the patient that an overdose did occur, and expects no harm to the patient due to this fraction of treatment. Patient has five more treatments."
The machine used was a Varying GammaMed+, SN 641053, using a 7.385 Ci Iridium-192 GammaMed 232 source.
Florida Incident number: FL19-071
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.