ENS Event | |
|---|---|
04:00 Aug 14, 2007 | |
| Title | Potential Medical Event |
| Event Description | A patient received a series of 3 vaginal cylinder HDR treatments on 08/14/07, 08/28/07, and 09/11/07 at the Arnett Cancer Care Center [also known as the Oncology Institute of Greater Lafayette which is the name on their license]. The treatment was planned with a source spacing of 5 millimeters. The electronic transfer of source spacing from the planned console to the treatment console did not function properly and the source spacing information was entered into the treatment console manually and inadvertently a source spacing of 2.5 millimeters was used. The dose distribution was different than planned due to the spacing difference, but the overall dose was correct. The prescribed dose per fraction was 700 cGray using an Ir-192 source with 13 dwell positions spaced 5 millimeters apart.
The physician has been notified and does not believe that there will be any adverse effects to the patient. At this time the patient has not been notified, but the licensee is attempting to contact her to inform her that the overall dose was delivered differently that planned. The licensee has taken corrective action to set the device default spacing at 5 millimeters and they will be revising their procedures to prevent reoccurrence. An inspection by the NRC Region 3 Inspector (Bob Gattone) on 10/16/07 discovered the source spacing error. 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 | |
|---|---|
| Oncology Institute Of Greater Lafayette Lafayette, Indiana (NRC Region 3) | |
| License number: | 13-32087-01 |
| Organization: | Oncology Institute Of Greater Lafay |
| Reporting | |
| 10 CFR 35.3045(a)(1) | |
| Time - Person (Reporting Time:+1543.65 h64.319 days <br />9.188 weeks <br />2.114 months <br />) | |
| Opened: | Phil Dittmer 11:39 Oct 17, 2007 |
| NRC Officer: | Joe O'Hara |
| Last Updated: | Oct 17, 2007 |
| 43727 - NRC Website | |
Oncology Institute Of Greater Lafayette with 10 CFR 35.3045(a)(1) | |
WEEKMONTHYEARENS 437272007-08-14T04:00:00014 August 2007 04:00:00
[Table view]10 CFR 35.3045(a)(1) Potential Medical Event 2007-08-14T04:00:00 | |