ENS 45007
ENS Event | |
|---|---|
07:00 Apr 14, 2009 | |
| Title | Agreement State Report - Potential Medical Misadministration |
| Event Description | The following information was obtained from the State of Washington via email:
On 15 April 2009, the licensee notified Washington Office of Radiation Protection by phone of a possible HDR (high dose-rate Remote after-loader Brachytherapy device) malfunction during a patient prostate treatment on 14 April 2009. The licensee discovered the event immediately upon termination of the treatment. The aluminum connector to needle 13 detached from the plastic guide tube. It is possible that the source wire or the dummy wire, during retraction, snagged on the seam between the aluminum connector and the plastic guide tube. The HDR is connected to the plastic guide tube, the plastic guide tube is attached (glued) to the aluminum connector, and the aluminum connector screws into the needles that are implanted in the patient. It is unknown whether the source wire successfully entered needle 13 as planned; or the source wire failed to enter needle 13 and therefore hung about 6 inches past the disconnected guide tube in open air, for the 32 second dwell time assigned to that particular needle. The event occurred with needle 13 of the 17 treatment needles. The source wire did retract normally after the event. The event did not interfere with the remaining treatment needles. Isotope and Activity involved: Iridium-192, 185.2 GBq (5.0 curies). Source serial number: 02-01-0080-001-0121. Overexposures: The dose possibly differed by approximately 180 rads to a small volume of the prostate in vicinity of needle 13. If so, then the total dose would be less than 5% under-dose for the total treatment. The dwell time for needle 13 could have resulted in as much as 12.5 Gy (1250 Rem) to a small area of skin on the inner thigh. Several subsequent inspections of the patient have found no skin reaction. After discussion with the attending physician and examination of the patient's skin, the licensee does not believe there was any clinically significant effect to the patient. Washington Incident Number: WA-09-015
Updated, corrected event narrative: On 15 April 2009, the licensee notified Washington Office of Radiation Protection by phone of a possible HDR (high dose-rate Remote after-loader Brachytherapy device) malfunction during a patient prostate treatment on 14 April 2009. The licensee discovered the event immediately upon termination of the treatment. The aluminum connector to needle 13 detached from the extension adaptor. The HDR is connected to the plastic guide tube, the plastic guide tube is attached to the extension adaptor (which includes the attached (glued) aluminum connector, and the aluminum connector screws into the needles that are implanted in the patient. The root causes of the failure of the adhesive that attached the aluminum connector to the plastic extension adaptor are: sterilization of the extension adaptor (manufacturer's written product information cautions that sterilization may cause adhesive failure), and reuse of extension adaptors (manufacturer's written product information recommends for single use only). It is unknown whether the source wire successfully entered needle 13 as planned; or the source wire failed to enter needle 13 and therefore hung about 6 inches past the disconnected guide tube in open air, for the 32 second dwell time assigned to that particular needle. The event occurred with needle 13 of the 17 treatment needles. The source wire did retract normally after the event. The event did not interfere with the remaining treatment needles. The dose possibly differed by approximately 180 rads to a small volume of the prostate in vicinity of needle 13. If so, then the total dose would be less than 5% under-dose for the total treatment. The dwell time for needle 13 could have resulted in as much as 12.5 Gy (1250 Rem) to a small area of skin on the inner thigh. Several subsequent inspections of the patient have found no skin reaction. After discussion with the attending physician and examination of the patient's skin, the licensee does not believe there was any clinically significant effect to the patient. 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 | |
|---|---|
| Cancer Care Northwest Pet Center Spokane, Washington (NRC Region 4) | |
| License number: | M0227 |
| Organization: | Wa Division Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+175.65 h7.319 days <br />1.046 weeks <br />0.241 months <br />) | |
| Opened: | Brandon Ketter 14:39 Apr 21, 2009 |
| NRC Officer: | Howie Crouch |
| Last Updated: | Jul 1, 2009 |
| 45007 - NRC Website | |
Cancer Care Northwest Pet Center with Agreement State | |
WEEKMONTHYEARENS 450072009-04-14T07:00:00014 April 2009 07:00:00
[Table view]Agreement State Agreement State Report - Potential Medical Misadministration 2009-04-14T07:00:00 | |