ENS 40352
ENS Event | |
|---|---|
20:15 Nov 24, 2003 | |
| Title | Agreement State Report - Dose to Patient Outside Intended Treatment Site |
| Event Description | [Radiation Safety Officer (RSO)] for Advocate Lutheran General Hospital called Illinois Emergency Management Agency on 11/24/03 at approximately 1415 to report an event involving a Novoste Intravascular Brachytherapy [IVB] procedure. Hospital RSO stated that at approximately 1100 on 11/24/2003 during an IVB procedure with a prescribed dose of 18.4 gray, the end of the 40mm source train was not visible at the anticipated location at the end of the catheter. The sources were stuck in an apparent kink in the catheter. The source train was immediately retracted into the safe shielded position in the unit. A second attempt was then made but the sources became stuck in the same area and were again immediately retracted.
The procedure was then terminated and an analysis of the event and dose estimates were performed. An unintended area of the heart was exposed to radiation from the source train for approximately 47 seconds in the first attempt and 10 seconds in the second. The estimated radiation dose calculated to the wrong area of the heart was estimated to be approximately 5 gray. Essentially none of the prescribed dose of 18.4 gray was delivered to the intended area of the heart as the source train was retracted before reaching the intended area. The patient has been notified that there was a problem encountered during the procedure and the physician will notify the patient shortly of the particulars involved with the unintended dose delivered. The physicians do not expect any adverse medical effects from this event. Hospital RSO stated that they will carefully review this event and enhance training for this procedure. Hospital RSO added that he will notify Novoste regarding this event and submit the required written report within 15 days. Illinois Event Report ID: IL030078, License Number: IL -01152-01 Source Information: NOVOSTE Model #A1767, Serial # 91834, Radionuclide: Sr 90, Activity: .0484 Curies |
| Where | |
|---|---|
| Illinois Emergency Mgmt. Agency Illinois (NRC Region 3) | |
| Organization: | Illinois Emergency Mgmt. Agency |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+15.28 h0.637 days <br />0.091 weeks <br />0.0209 months <br />) | |
| Opened: | Joe Klinger 11:32 Nov 25, 2003 |
| NRC Officer: | Gerry Waig |
| Last Updated: | Nov 25, 2003 |
| 40352 - NRC Website | |
Illinois Emergency Management Agency with Agreement State | |||
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