ENS 42707

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v t e ENS Event
04:00 Jul 3, 2006
Title	Agreement State Report - Medical Misadministration Using High Dose Rate Afterloader
Event Description	On 7/17/06 the State of Maryland received a report from the Anne Arundel Medical Center in Annapolis, Maryland of a potential medical misadministration using a high dose rate afterloader. Approximately two to three weeks ago a patient was administered a dose using a Varian VariSource 200 HDR brachytherapy afterloader to treat a lung tumor. During the dose administration the catheter was determined to be about ten centimeters short of the planned location for the dose. Because of the mispositioning or the catheter, an unintended dose of less than 100 centigray was given to patient's vocal chord area. The lungs received a dose of 5 gray. The licensee notified the patient of the issue. A licensee physician examined the patient today and determined that there was no erythema and that there would be no adverse medical effects in the unintended dose area. The licensee reported that a human error not a device error resulted in the misadministration. The State will be conducting follow-up investigations into this incident to include reviewing the licensee's determination of the cause, as well as, determining why the event was not reported until 2 to 3 weeks after it had occurred. Typically a 10 curie Iridium-192 source is used in this type of instrument. * * UPDATE AT 1100 EDT ON 07/18/06 FROM RAY MANLEY TO S. SANDIN * * * The patient did not receive a dose of 5 gray to the lungs as described above. This was the prescribed dose. Also, the information is preliminary pending completion of the follow-up investigation. Notified R1DO (Kinneman) and NMSS (Morell).

ENS 42707 +/-
Where
Anne Arundel County Medical Center Annapolis, Maryland (NRC Region 1)
License number:	MD-0300106
Organization:	Maryland Dept Of The Environment
Reporting

Agreement State
Time - Person (Reporting Time:+346.92 h14.455 days <br />2.065 weeks <br />0.475 months <br />)
Opened:	Ray Manley 14:55 Jul 17, 2006
NRC Officer:	Pete Snyder
Last Updated:	Jul 18, 2006
42707 - NRC Website
v • d • e

v t e Emergency Notification System
Anne Arundel County Medical Center with Agreement State
WEEKMONTHYEAR2006-07-03T04:00:00 [Table view]
[ENS list for Anne Arundel County Medical Center]

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