ENS 44911

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v t e ENS Event
04:00 Mar 17, 2009
Title	Pennsylvania Agreement State Report - Medical Event
Event Description	The following information was received from the State of Pennsylvania via email: A female patient was to receive HDR twice a day for a total of 10 treatments with an expected dose of 34Gy via mammosite treatment. A dummy wire was inserted into the balloon to check and measure the tube length for dosage calculations. A CT scan was performed daily to verify the position of the treatment site. Treatment calculations were done, reviewed, approved, and treatment began Monday, February 23, 2009. [On] Friday, February 27, 2009, a different therapy physicist was checking the patients charts and thought that there may have been an error. [On] Monday, March 2, 2009, the original physicist checked the findings of the different therapy physicist and discovered that there had been an error in the placement of the source during the treatment. The source was not fully inserted into the balloon, but was 3cm from where it should have been, thereby resulting not only in a large difference in the tumor dose received (approx. 30% of intended) but also in a severe dosage to non-intended areas of the patient. The physicist, RSO and two licensee's radiation oncologist reviewed the situation once it was discovered. The patient is being followed for any sequelae (pathological conditions) to the event. It was reported that erythema (dilated capillaries) is developing consequential to the event. Follow ups are expected to occur weekly. The oncologist has discussed the event with the patient. PA Case # PA090011 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.

ENS 44911 +/-
Where
Western Pennsylvania Hospital Pittsburgh, Pennsylvania (NRC Region 1)
License number:	PA-0121
Organization:	Pa Bureau Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+5.08 h0.212 days <br />0.0302 weeks <br />0.00696 months <br />)
Opened:	Jennifer Kelly 09:05 Mar 17, 2009
NRC Officer:	Howie Crouch
Last Updated:	Mar 17, 2009
44911 - NRC Website
v • d • e

v t e Emergency Notification System
Western Pennsylvania Hospital with Agreement State
WEEKMONTHYEAR2009-03-17T04:00:00 [Table view]
[ENS list for Western Pennsylvania Hospital]

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