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Event Notification Report for June 05, 2020

U.S. Nuclear Regulatory Commission
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Event Reports For
6/4/2020 - 6/5/2020

** EVENT NUMBERS **


54728

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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 Friday, June 05, 2020
Friday, June 05, 2020