ENS Event | |
|---|---|
08:00 Nov 17, 2003 | |
| Title | Patient Received an Overdose During a Brachytherapy Procedure |
| Event Description | The licensee's RSO reported on 18 November 2003, that a patient, at Swedish Medical Center, Providence Campus, was scheduled to receive an intravascular Brachytherapy procedure that involved the use of a NOVOSTE Beta-Cath device. The device, Serial Number ZB638, employed a total activity of 2907 Megabecquerels (78.56 millicuries) of Strontium 90/Yttrium 90, in a sealed source-train, Serial Number 91837. The cardiologist was unable to insert the source-train for the treatment because, as reported by the RSO, it was into a small artery and the routing did not follow a direct path. This resulted in a 143 second, 13.78 Gray (1378 Rad), exposure to healthy patient tissue.
The source-train was partially inserted into the patient when the cardiologist experienced difficulty. A 143 second exposure time elapsed before the cardiologist withdrew the source-train even though medical center procedure requires the sources to immediately be withdrawn once a problem is understood. The delay apparently occurred as the cardiologist first worked to fully insert the source-train and then discussed correcting the problem with the oncologist. The cause of the exposure was failure to follow established procedures. The cardiologist has been suspended from further licensed activities until the details of the event are fully understood. It is anticipated that no health affects to the patient will be realized as a result of the exposure. A DOH staff health physicist will pursue additional details of the event. There is no media attention at this time. Patient and referring physician were notified. |
| Where | |
|---|---|
| Swedish Medical Center Seattle, Washington (NRC Region 4) | |
| License number: | WN-M008-1 |
| Organization: | Wa Division Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+33.98 h1.416 days <br />0.202 weeks <br />0.0465 months <br />) | |
| Opened: | Arden Scroggs 17:59 Nov 18, 2003 |
| NRC Officer: | Chauncey Gould |
| Last Updated: | Nov 18, 2003 |
| 40337 - NRC Website | |
Swedish Medical Center with Agreement State | |
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