Event Notification Report for June 05, 2020
U.S. Nuclear Regulatory Commission Event Reports For ** EVENT NUMBERS ** |
54728 |
Agreement State | Event Number: 54728 |
Rep Org: ALABAMA RADIATION CONTROL Licensee: USA Health University Hospital Region: 1 City: Mobile State: AL County: License #: 584 Agreement: Y Docket: NRC Notified By: Cason Coan HQ OPS Officer: Brian Lin |
Notification Date: 05/27/2020 Notification Time: 08:06 [ET] Event Date: 05/26/2020 Event Time: 15:30 [CDT] Last Update Date: 05/27/2020 |
Emergency Class: Non Emergency 10 CFR Section: Agreement State |
Person (Organization): JOSEPH DEBOER (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL) |
Event Text
AGREEMENT STATE REPORT - POSSIBLE ADMINISTRATION AT THE WRONG TREATMENT SITE The following information was received from the state of Alabama via email: "The Alabama Department of Public Health Office of Radiation Control was notified on May 26, 2020, at about 1620 CDT by the Radiation Safety Officer (RSO) of the University of South Alabama Health University Hospital (license 584) of a possible misadministration via HDR [high dose rate] afterloader. The RSO stated that the patient was apparently treated at the wrong treatment site on May 26, 2020 around 1530 CDT; the prescribed dose for the fraction was 700 cGy (treatment course to total 2100 cGy). The licensee is currently working to reconstruct dosimetry at the time of this report, and is unsure of the variance from the prescribed dose. The licensee is authorized to possess an Elekta 136149A02, with a maximum of 12 Ci of Ir-192." Alabama Incident Report No.: 20-09. 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. |
Page Last Reviewed/Updated Wednesday, March 24, 2021
Page Last Reviewed/Updated Wednesday, March 24, 2021