ENS 45788
ENS Event | |
|---|---|
05:00 Mar 23, 2010 | |
| Title | Agreement State Report - Improper Dosage Given During Medical Treatment |
| Event Description | The following information was received by e-mail:
On March 25, 2010, Mayo Clinic notified the Minnesota Department of Health of an HDR [High Dose Rate After Loader] medical event. The patient was prescribed four fractions of 4 Gy for a biliary HDR treatment. The catheter had been placed and imaged. A dummy source was pushed into the catheter until it met resistance that was assumed to be the end of the catheter. In fact, the resistance was a tight bend approximately 17 centimeters (6.69 inches) short of the end. The distance that was thought to be the end of the catheter was incorrectly used for the treatment distance and the patient was subsequently treated. Prior to treatment the following day, a dummy source was again inserted. That source extended beyond the programmed distance. An x-ray revealed that the end of the catheter was beyond the initial treatment location. For the first two fractions, the HDR source was 17 cm from its intended treatment location. This resulted in the tumor receiving only 30 percent of the intended fractional dose and resulted in the duodenum (where the HDR source was located) receiving more than 50 rem and more than 50 percent of planned. 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 | |
|---|---|
| Mayo Clinic Rochester, Minnesota (NRC Region 3) | |
| License number: | 1047-205-55 |
| Organization: | Minnesota Department Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+58.45 h2.435 days <br />0.348 weeks <br />0.0801 months <br />) | |
| Opened: | George Johns 15:27 Mar 25, 2010 |
| NRC Officer: | Vince Klco |
| Last Updated: | Mar 25, 2010 |
| 45788 - NRC Website | |
Mayo Clinic with Agreement State | |
WEEKMONTHYEARENS 566712023-08-09T04:00:0009 August 2023 04:00:00
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