ENS 43606
ENS Event | |
|---|---|
05:00 Aug 29, 2007 | |
| Title | Agreement State Report - Higher than Prescribed Dose |
| Event Description | On 08/29/07 at 10:55 a.m., the agency received a call from [the] RSO for the licensee, reporting a High Dose Remote Afterloader (HDR) misadministration that occurred on 08/22/07. The RSO reports that today, 08/29/07, it was discovered that a patient received one HDR treatment on 08/22/07, with 2500 cGy being delivered instead of the planned dose of 500 cGy per fraction for 5 fractions. The RSO reports that the unit was a Varian VariSource loaded with Ir-192. The RSO will include model & serial numbers for the unit & source in his 15-day report to the agency.
The misadministration was discovered today after an independent physicist's review of the treatment plan. The RSO stated the patient denies any symptoms and was being seen by the Radiation Oncologist. He stated the patient's family and referring physician were also notified. Texas Incident No.: I-8439 Texas Event Report No.: TX-07-43606
Telephone call placed to (deleted), Ph.D., L.M.P., RSO for the licensee for updated information from 08/29/07 after the patient was seen by the Radiation Oncologist: Deleted reports that the patient was seen by the Radiation Oncologist & is being observed in a 'wait & watch' following. (Deleted) reported that the patient's Pulmonologist has taken over & (deleted) stated the Pulmonologist said 'We may have gotten lucky & even cured the guy.' The patient is still reported as doing well, with no adverse side effects being reported, as stated by (deleted). (Deleted) stated a CT was performed prior to the planned second treatment on 08/29/07, with no adverse effects viewed on the CT scan. " ***ADDITIONAL NOTE TO ORIGINAL REPORTED INFORMATION*** Deleted reported on 08/29/07 that this HDR misadministration occurred as a result of the incorrect isodose line being chosen & entered into the treatment planning system. (Deleted) reported that the treatment planning system then normalized the calculations to this incorrect isodose line & the resulting treatment dose was what was delivered on the first treatment day. (Deleted) stated the Oncologist signed & approved this treatment plan & that (deleted) himself, did a second calculation check on the treatment plan. The calculation error was caught by an independent physicist PRIOR to the planned second treatment. Incident Investigations will continue to update this incident as current information is received. Incident Investigation personnel plan to conduct an onsite investigation upon receipt and review of the required 15-day report from the licensee. FSME EO (Sandra Wastler) & R4DO (R. Nease) notified.
On 08/29/07 at 10:55 a.m., the agency received a call from (delete), L.M.P., RSO for the licensee, reporting a High Dose Remote Afterloader (HDR) misadministration that occurred on 08/22/07. The RSO reports that today, 08/29/07, it was discovered that a patient received one HDR treatment on 08/22/07, with 2500 cGy being delivered instead of the planned dose of 500 cGy per fraction for 5 fractions. The RSO reports that the unit was a Varian VariSource loaded with Ir-192. The RSO will include model & serial numbers for the unit & source in his 15-day report to the agency. The misadministration was discovered today after an independent physicist's review of the treatment plan. The RSO stated the patient denies any symptoms & was being seen by the Radiation Oncologist. He stated the patient's family & referring physician were also notified. R4DO (Pruett) & FSME (Jack Davis) notified. 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. |
| Where | |
|---|---|
| Physician Reliance, Lp Texas Oncology Fort Worth, Texas (NRC Region 4) | |
| License number: | L05545-000 |
| Organization: | Texas Department Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+8.7 h0.363 days <br />0.0518 weeks <br />0.0119 months <br />) | |
| Opened: | Latischa Hanson 13:42 Aug 29, 2007 |
| NRC Officer: | Pete Snyder |
| Last Updated: | Sep 4, 2007 |
| 43606 - NRC Website | |
Physician Reliance, Lp Texas Oncology with Agreement State | |
WEEKMONTHYEARENS 436062007-08-29T05:00:00029 August 2007 05:00:00
[Table view]Agreement State Agreement State Report - Higher than Prescribed Dose 2007-08-29T05:00:00 | |