The following was received via fax from the State of
Colorado.
A medical licensee notified the [Colorado Department of Health] of a misadministration during a HDR [High Dose Rate Afterloader] procedure. A positioning error resulted in an estimated dose of 700 Rads to the wrong site.
No other details are available at this time.
The Department has initiated an investigation of this incident.
The licensee did not provide the State with an event date and time in the initial event report.
The following information was received by the State of Colorado via fax:
The [State of Colorado Department of Health] received the following information from the medical physicist who reported the misadministration involving a therapy treatment with a High Dose rate Remote Afterloader (HDR) at Penrose St. Francis Hospital in Colorado Springs, Colorado.
-The date of the misadministration was 7/21/09.
-Because of the error, the dose was delivered to the entrance of the vagina, rather than intrauteral.
-The patient's physician and the patient have been informed of the incident.
-The applicator used in this procedure uses a collet to hold a 3 mm source tube in place. There may have been a problem with the collet, which allowed the source tube to move.
-The licensee instituted corrective actions, which include additional training for all staff involved in HDR therapy treatments, and an additional check of the applicator prior to start of treatment.
A full report from the medical physicist is expected within the next 7 days.
No other details are available at this time.
The Department has initiated an investigation of this incident.
Notified R4DO (Jones) and FSME EO (Villamar).
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.