ENS 40971

v t e ENS Event
19:00 Aug 18, 2004
Title	Agreement State Report- Therapeutic Misadministration
Event Description	Therapeutic misadministration from HDR [High Dose Rate brachytherapy]. Patient was scheduled for three HDR retreatments for cancer between the urethra & bladder wall. The treatment dose/fraction was supposed to be 300 cGy [centiGray] to a 7 mm radius distance from the source, & the length of the treatment plan was 3 cm. They used a Varian catheter & measuring wire. When they inserted the measuring wire, they thought they were at the end of the catheter, but they were actually about 20 cm short. The source for two treatments, on August 18 and 19, was actually located about 10 cm from the end of the penis, exterior to the body. They estimate the tumor site only got about 10 cGy, and the penis may have received approximately the same dose it would have received had the source been inserted into the correct location. The root cause appears to be an error on the part of the medical physicist. The patient is 93 years old, and both the radiation oncologist and the primary care physician believe he should not be told. The third treatment was performed correctly, and they have scheduled him for two additional treatments. They believe there will be no impact on the patient.

ENS 40971 +/-
Where
Providence St. Joseph Medical Center Burbank, California (NRC Region 4)
License number:	CA0059-19
Organization:	California Radiation Control Prgm
Reporting

Agreement State
Time - Person (Reporting Time:+47.68 h1.987 days <br />0.284 weeks <br />0.0653 months <br />)
Opened:	K. Kaufman 18:41 Aug 20, 2004
NRC Officer:	John Mackinnon
Last Updated:	Aug 20, 2004
40971 - NRC Website
v • d • e

v t e Emergency Notification System
Providence St. Joseph Medical Center with Agreement State
WEEKMONTHYEAR2004-08-18T19:00:00 [Table view]
[ENS list for Providence St. Joseph Medical Center]

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