ENS 46860
ENS Event | |
|---|---|
04:00 Jun 20, 2007 | |
| Title | Agreement State Report - Medical Misadministration Using Hdr Afterloader |
| Event Description | The following was received from the State of New York via fax:
New York law prohibits the release of any identifiers In cases of medical events. Therefore, the facility name etc. is not contained in this report. The licensee telephoned [the State of New York] on 6/20/07, to report misadministration on 6/19/07. Patient was a 73 year old woman receiving the second of her 5 fractions of HDR for cancer of the cervix. It was a ring and tandem setup. 600 cGy prescribed to point A in the cervix. Patient moved about halfway through the treatment and with the applicator about 6 cm inferior to the cervix, the cervix received about 382 cGy while the vagina received about 218 cGy. During a conference call between Bureau staff and facility staff including radiation oncologist, physicist, and administrator, it was learned that the patient had had 10 children and muscles were not tight. Prior to the start of the treatment, she complained of discomfort from the foley catheter due to bladder distention and the clamp was loosened a bit. She continued to be uncomfortable and moved during the treatment of 644 seconds. Therapists reassured her and completed the treatment, despite the movement. It was discovered later that the applicator had slid inferior by about 6 cm. The radiation oncologist believes that the 218 cGy to the vagina will not impact the patient adversely because there is some disease in that area. The patient and the referring physician have been informed. The physician does not plan to make up for the deficit dose to point A in the cervix. Facility submitted an RCA and to prevent recurrence, they have implemented the following measures. (1) Minimize time between applicator insertion and treatment. (2) Use of stabilizing devices at the time of insertion to minimize applicator movement (3) Use anatomical markings at the time of device insertion to help verify applicator position just prior to and during treatment (4) Expand patient instruction with increased emphasis on need to remain still and (5) Staff education on patient monitoring prior to and during treatment, with applicator position verification added to physics checklist. These are sufficient. As of 5/13/09, the patient is free of disease and complications. This event may be closed. HDR Brachytherapy misadministration (NYS DOH Internal Tracking No. 548). New York Event Number NY-11-01. 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 | |
|---|---|
| None Provided New York (NRC Region 1) | |
| Organization: | New York State Dept. Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+34306.6 h1,429.442 days <br />204.206 weeks <br />46.993 months <br />) | |
| Opened: | None Provided 14:36 May 19, 2011 |
| NRC Officer: | Joe O'Hara |
| Last Updated: | May 19, 2011 |
| 46860 - NRC Website | |
None Provided with Agreement State | |
WEEKMONTHYEARENS 468612007-10-02T04:00:0002 October 2007 04:00:00
[Table view]Agreement State Agreement State Report - Patient Received Twice the Prescribed Dose ENS 468592007-07-02T04:00:0002 July 2007 04:00:00 Agreement State Agreement State Report - Medical Misadministration Using Hdr Afterloader ENS 468602007-06-20T04:00:00020 June 2007 04:00:00 Agreement State Agreement State Report - Medical Misadministration Using Hdr Afterloader 2007-07-02T04:00:00 | |