On January 4, St. James' Hospital and Health Center's medical physicist called to report that medical event had occurred involving a patient at their Cancer Center Institute. [The medical physicist] advised that a series of high dose rate (
HDR) afterloading fractions using 10 Ci of
Ir-192 that had been conducted on 11/29, 12/6, 12/13 and 12/20 had inadvertently caused the irradiation, not of the cancerous target intended but instead, a portion of the patient's inner thighs. The delivered radiation dose to the skin was 2,000 Rad and the dose to the intended treatment area was zero.
[The medical physicist] indicated that the error had been identified as part of a 'chart audit' that was conducted prior to performing the next similar routine treatment of a subsequent patient. Computerized dosimetry planning records showed that although the prescribed treatment was to occur with an automated source travel distance of 120 cm, the actual data point used during the treatment phase was a travel distance of only 100 cm. The patient was asked to come to the hospital on the afternoon of January 4 for a consultation. During that visit the responsible authorized radiation oncologist confirmed reddening of the skin on both inners thighs of approximately 3 square centimeters. [The oncologist] indicated that the skin damage is a 'superficial ulceration with no necrosis of the tissue' and he expected healing to be completed in 2-4 weeks. [The oncologist] has made arrangements to meet with the patient weekly to monitor her progress during that time. HDR afterloader treatments have been rescheduled to occur next week.
The state also said that it appears that correct dose was administered to the wrong location because of a human error not an equipment malfunction.
Other pertinent data related to this event: Type of procedure: BRACHYTHERAPY, Intended Dose: 2000 RAD, Form of Radioactive Material: SEALED SOURCE, Radionuclide: IR-192, Activity: 10 Ci.
Equipment Information: Manufacturer: ALPH-OMEGA SERVICES VARIAN, Model Number: VS2000, Serial Number: 02011368001112006101.
The Illinois Emergency Management Agency will be following up on this incident. This report is IL report number 070001.
A "Medical Event" may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.
- * *UPDATED ON 3/13/07 BY KOZAL TO EXPORT TO NRC PUBLIC WEBSITE* * *