ENS Event | |
|---|---|
06:00 Mar 11, 2004 | |
| Title | Medical Event Involving Treatment to Wrong Location |
| Event Description | As a result of a retrospective review of HDR brachytherapy cases, a medical event was discovered. This event occurred on March 11, 2004, which involved a single esophageal HDR brachytherapy treatment. In this case, a 62 year old female patient, was treated with a Nucletron High Dose Rate (HDR) brachytherapy remote afterloader for esophageal cancer . The physician Authorized User (AU) prescribed a dose of 500 cGy at 0.5 cm from the surface of a N/G tube (naso-gastric tube) for an active length of 8.0 cm using a 8.49 Curie Iridium-192 source. The treatment plan called for 17 indexer step positions at 5.0mm spacing to begin at dwell position 23 and terminating at dwell position 39. The medical physicist entered 17 indexer step positions with 5.0 mm spacing at dwell positions 1 through 17 and treatment was delivered.
As the intended delivery site was to be delivered an intended dosage of 500 cGy for one fraction for a total of 500 cGy, the dose delivered to the unintended site was 500 cGy while the intended treatment site was not treated. This patient is now deceased. It is not believed this medical event was a significant contributing factor in the cause of death when consideration of the prognosis of the disease is given. Although this medical event occurred March 11, 2004, it was discovered 17:45 ET on September 27, 2005, as a result of a retrospective review. The licensee has notified Region 3 (Madera and Mulay) about this event. |
| Where | |
|---|---|
| St.Vincent Hospital Indianapolis, Indiana (NRC Region 3) | |
| License number: | 13-00133-02 |
| Organization: | St. Vincent Hospital |
| Reporting | |
| 10 CFR 35.3045(a)(3) | |
| Time - Person (Reporting Time:+13596.27 h566.511 days <br />80.93 weeks <br />18.624 months <br />) | |
| Opened: | Ed Wroblewski 17:16 Sep 28, 2005 |
| NRC Officer: | Bill Huffman |
| Last Updated: | Sep 28, 2005 |
| 42023 - NRC Website | |
St.Vincent Hospital with 10 CFR 35.3045(a)(3) | |
WEEKMONTHYEARENS 420232004-03-11T06:00:00011 March 2004 06:00:00
[Table view]10 CFR 35.3045(a)(3) Medical Event Involving Treatment to Wrong Location 2004-03-11T06:00:00 | |