ENS 41162

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v t e ENS Event
17:30 Oct 26, 2004
Title	Agreement State Report - Medical Event
Event Description	This event involved an HDR brachytherapy unit [Varian Medical Systems, Inc. Model GammaMed plus, serial number E159; with sealed source Model GammaMed 232, serial number 24-07-4445-004-082504-11622-71 (connector serial number D24E445)]. The female patients larynx cancer treatment plan called for four HDR brachytherapy treatments. On October 26, 2004, two HDR brachytherapy treatments were given. Before the third treatment was to be given, on October 27, 2004, an error was discovered. The prescribing physician stopped the treatment until dosimetry information was completed. The third treatment was not given. The error was caused because a circular tool was used to mark the treatment site. The diameter of the circle was used when the radius should have been applied. As a result, the area treated was 2 cm away from the defined locus instead of 1 cm. The total source length treated was 11 cm, (approximately 1 cm diameter cylinder surrounding the brachytherapy source placed inside a tracheotomy tube). The prescribed dose was 500 cGy (centiGray) to the entire 11 cm length. The worse case patient dose scenario was that the patient received 2,756 cGy at one dwell position out of 23 dwell positions along the 11 cm treatment length. The dose delivered would have been 551% greater than the prescribed dose at the position respective to the worst-case scenario. The licensee does not anticipate any adverse health affects to the patient. The Utah Division of Radiation Control is currently investigating this event.

ENS 41162 +/-
Where
Lds Hospital Salt Lake City, Utah (NRC Region 4)
License number:	UT 1800102
Organization:	Utah Division Of Radiation Control
Reporting

Agreement State
Time - Person (Reporting Time:+72.92 h3.038 days <br />0.434 weeks <br />0.0999 months <br />)
Opened:	Julie Felice 18:25 Oct 29, 2004
NRC Officer:	Bill Gott
Last Updated:	Oct 29, 2004
41162 - NRC Website
v • d • e

v t e Emergency Notification System
Lds Hospital with Agreement State
WEEKMONTHYEAR2004-10-26T17:30:00 [Table view]
[ENS list for Lds Hospital]

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