ENS 46609
ENS Event | |
|---|---|
06:00 Feb 10, 2011 | |
| Title | Agreement State Report - Leaking Mamosite Balloon Catheter Possibly Affected Dose |
| Event Description | The State of Iowa reported the following via email:
The licensee reported a potential medical event that had occurred on Thursday, February 10, 2011. A patient was under going breast cancer treatment using a Nucletron Corporation Micro Selection High Dose Rate Afterloader (HDR). The HDR contained a 5.2 curie Iridium-192 sealed source. The patient was scheduled to receive a total dose of 3400 cGy in ten (10) fractions of 340 cGy each over a five day period. The licensee performs a CT scan on the patient before each fraction to confirm the positioning of the balloon catheter. On the morning of Thursday, February 10, 2011 the patient arrived for the seventh fraction. The licensee's CT scanner was not operable at the time so the Authorized User (AU) (Radiation Oncologist) imaged the patient using ultrasound. The AU noticed at the time that the patient had some drainage from the surgical incision but the results of the ultrasound appeared [to show] that the balloon catheter was correctly placed. The patient then received the seventh fraction. When the patient returned for the eighth fraction in the afternoon of the 10th the licensee's CT scanner was operable. This scan showed that the balloon catheter had completely leaked out all of the fluid. The AU and Medical Physicist made the decision to not perform the eighth fraction due to the possibility that the patient may have received a double dose (680 cGy) during the previous fraction. The patient, referring physician and surgeon were then notified. The surgeon removed the leaking balloon catheter and replaced it with a new catheter. The patient completed fraction nine on the morning of Friday, February 11, 2011 and is scheduled for fraction ten and treatment completion in the afternoon of the 11th. The AU and Medical Physicist do not believe that this event will result in any adverse complications to the health of the patient. The licensee will continue to investigate this event and provide a written report to IDPH within 15 days of the occurrence. Iowa Item Number: IA110001 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 | |
|---|---|
| Mercy Medical Center Cedar Rapids, Iowa (NRC Region 3) | |
| License number: | 0339157HDR |
| Organization: | Iowa Department Of Public Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+31.65 h1.319 days <br />0.188 weeks <br />0.0434 months <br />) | |
| Opened: | Randal Dahlin 13:39 Feb 11, 2011 |
| NRC Officer: | Pete Snyder |
| Last Updated: | Feb 11, 2011 |
| 46609 - NRC Website | |
Mercy Medical Center with Agreement State | |
WEEKMONTHYEARENS 487802013-01-17T06:00:00017 January 2013 06:00:00
[Table view]Agreement State Agreement State Report - Prostate Seed Implant Underdose ENS 466092011-02-10T06:00:00010 February 2011 06:00:00 Agreement State Agreement State Report - Leaking Mamosite Balloon Catheter Possibly Affected Dose ENS 459112010-04-29T06:00:00029 April 2010 06:00:00 Agreement State Agreement State Report - Potential Dose to Embryo or Fetus ENS 465012008-08-12T06:00:00012 August 2008 06:00:00 Agreement State Agreement State Report - Medical Event- Prostate Brachytherapy Treatment Underdose 2013-01-17T06:00:00 | |