AGREEMENT STATE REPORT - MEDICAL EVENT
The following was received via email from the Florida Bureau of Radiation:
"At 1605 [EDT], [on June 9, 2020, the University of Florida] RSO [Radiation Safety Officer] reported a radiation overdose at the Human Use Facility, Jacksonville, FL. The physicists began reviewing the patient's treatments on Friday, June 5, 2020. They were evaluating an Excel spreadsheet used to calculate monitoring units (MUs) for double scatter proton therapy and after 15 fractions caught an error. The intended dose was 80 Gy. At this point in the treatment 30 Gy should have been delivered, but instead the current total is approximately 50 Gy. The treating physician was informed and they informed the patient. It has been concluded that the patient will return to complete treatment and receive in total 59 Gy, which is a commonly used fractionation scheme. The doses to the organs at risk (OARs) are within the tolerance of the treatment goals of the delivered fractionation scheme. They are continuing to review the issue and will send a report as soon as possible."
Incident Number: FL20-066
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. |