ENS 42359
ENS Event | |
|---|---|
05:00 Dec 14, 2003 | |
| Title | Agreement State Report Involving a Medical Misadministration |
| Event Description | The following information was received via facsimile:
NY-06-002 HDR Brachytherapy medical event (NYS DOH Internal Tracking; No. 13) New York law prohibits the release of any identities in cases of medical events. Therefore the facility name, etc., is not contained in this report. RSO reported a medical misadministration involving a female patient treated on 5/12-14/2003 with SYED(needles)/HDR (Varian unit). Apparently there was an error, with respect to the area treated (incorrect dwell positions), which was not discovered until a final chart review. The treatment plan and double check of the calculations were performed as required. A different physicist than the one who did the treatment plan and double checks discovered the error. The facility submitted a written report. According to the report, since the original catheters had been discarded, reconstructing the scenario to the best of their ability, they concluded that all catheters and connecting tubes had the same lengths as previous similar implants. The measurement of 4 catheters on the first implant day obtained a catheter length of 119.8 cm. It was not repeated for the other 7 catheters and not double-checked by measurement by another physicist. However, the number, 119.8 cm is different from what they usually get for this type of procedure. Therefore, they concluded that the error occurred at this stage of the planning: i.e., (1) the planner did not verify that numbers were similar to what they usually get. (2) physics double check prior to the procedure did not include a second measurement nor did it check if the numbers were reasonable. The measurement was incorrect. Their corrective actions, if followed strictly, should prevent this error from happening again. Target (Tumor) Intended 2000 cGy. Delivered 150 cGy. Normal Tissue Expected 150 cGy. Delivered 2000 cGy. The patient was seen by her gynecological oncologist. This physician and the radiation oncologist determined that the patient should not be adversely affected because the dose was within tolerance of tissue including those of the vagina, rectum and bladder. However they were concerned that the tumor bed did not receive an adequate radiotherapy dose. The patient received additional low dose brachytherapy treatment. The LDR was given on 6/27/03, 1200 cGy to 0.5 cm from the cylinder surface. This treatment was delivered as intended. |
| Where | |
|---|---|
| Not Disclosed By State Law New York (NRC Region 1) | |
| Organization: | New York State Dept. Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+19234.42 h801.434 days <br />114.491 weeks <br />26.347 months <br />) | |
| Opened: | R. Dansereau (Via Fax) 15:25 Feb 22, 2006 |
| NRC Officer: | Steve Sandin |
| Last Updated: | Feb 22, 2006 |
| 42359 - NRC Website | |
Not Disclosed By State Law with Agreement State | |
WEEKMONTHYEARENS 423602005-11-29T05:00:00029 November 2005 05:00:00
[Table view]Agreement State Agreement State Report Involving a Broken I-125 Brachytherapy Seed ENS 423642004-11-05T05:00:0005 November 2004 05:00:00 Agreement State Agreement State Report Involving an I-131 Radiopharmaceutical Misadministration ENS 423632004-09-29T05:00:00029 September 2004 05:00:00 Agreement State Agreement State Report Involving an Intravascular Brachytherapy Event ENS 423622004-05-26T05:00:00026 May 2004 05:00:00 Agreement State Agreement State Report Involving an Intravascular Brachytherapy Event ENS 423592003-12-14T05:00:00014 December 2003 05:00:00 Agreement State Agreement State Report Involving a Medical Misadministration ENS 423582003-04-17T05:00:00017 April 2003 05:00:00 Agreement State Agreement State Report Involving a Radiopharmaceutical Misadministration 2005-11-29T05:00:00 | |