On 10/11/04 a 49 year old female patient received the first of two treatments for endometrial cancer. A total dose of 700 centiGray was prescribed to be delivered in two (2) 350 cGy fractions using a 1500 mm length catheter containing a 7.035 curies
Ir-192 source (duration 189 seconds). Due to an error on the part of the Health Physicist, the 995 mm length catheter was used. This resulted in a calculated dose of less than 1 cGy to the thigh at a distance of 505 mm from the intended site. There are no expected adverse consequences.
Both the patient and prescribing physician were informed. A new treatment plan has been developed and the patient rescheduled. Corrective actions are to be determined. The licensee informed Region 3 (Mike Lafranzo).
- * * UPDATE ON 10/21/04 @ 1246 BY ED WROBLEWSKI TO CHAUNCEY GOULD * * *
The following text is an updated corrected version of the above initial report which was submitted by the licensee after consulting with Region 3.
On 10/11/04 a 49 year old female patient received what was to be the first of two High Dose Rate (HDR) treatments for endometrial cancer using a remote afterloading unit. The physician planned two fractions of 350 cGy for a total of 700 cGy at 0.5 cm from the GYN cylinder (2.0cm) wall using a 7 Ci Ir-192 source. The GYN cylinder is connected to the HDR unit using a 1500 mm transfer tube. A treatment of 189 seconds with an active length of 5 cm was to be treated with an indexer position of 1500 mm, Due to an error on the part of the medical physicist, an indexer length of 995 was programmed into the treatment unit. This resulted in the source not entering the patient. The source remained positioned in the transfer tube for the treatment duration at an estimated distance of 35-50 cm from the patient's skin. This resulted in a calculated dose between 1.4 - 4.3 R to the patient's skin. There are no expected adverse consequences.
Notified Reg 3 RDO (
Julio Lara) and
NMSS EO (Sandra Wastler)