Event Notification Report for January 25, 2013

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
01/24/2013 - 01/25/2013

** EVENT NUMBERS **

Agreement State	Event Number: 48678
Rep Org: OHIO BUREAU OF RADIATION PROTECTION Licensee: AKRON GENERAL MEDICAL CENTER Region: 3 City: AKRON State: OH County: License #: 02120-78-0000 Agreement: Y Docket: NRC Notified By: KARL VON AHN HQ OPS Officer: STEVE SANDIN	Notification Date: 01/16/2013 Notification Time: 16:46 [ET] Event Date: 01/15/2013 Event Time: [EST] Last Update Date: 01/16/2013
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): TAMARA BLOOMER (R3DO) FSME EVENTS RESOURCE (EMAI)

Event Text

AGREEMENT STATE REPORT - MISPLACEMENT OF BRACHYTHERAPY SOURCE DURING MEDICAL TREATMENT

The following information was provided by the State of Ohio:

"The Ohio Department of Health Bureau of Radiation Protection was notified by the licensee RSO of a potential medical event. A patient was planned for a vaginal cylinder (HDR) procedure. Approved plan prescribed 4 Gy to target organ (vaginal canal) and 4.61 Gy to rectum. On the first of three fractions, the cylinder was inserted by the Authorized User (AU) in the rectum instead of the vaginal canal. The AU reviewed the film and approved the position for treatment. The physicist determined that the rectum received approximately 6.1 Gy (132% of the prescribed dose). At the time of this report it appears that the intended treatment target received less than 2 Gy (less than 50% of prescribed dose)."

The device used is a remote afterloader HDR manufactured by Nucletron, Model Microselectron S/N 31472, containing a single sealed source of 4.15 Ci Ir-192. The cause is identified as human error.

Item Number: OH130001

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.

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