The following information was obtained from the State of
Virginia via fax:
On August 7, 2011, the licensee's RSO received notification of an incident. A patient was treated for bronchial/trachea carcinoma using temporary brachytherapy employing a HDR delivery system. Subsequent to treatment, it was realized that dwell positions were misrepresented on the approved treatment plan. Reconstruction of the applicator position led to the conclusion that dose to organs or tissue other than the treatment site received more than 50 Rem and more than 50% of the expected dose. Licensee notified Virginia Department of Health on August 17, 2011. Referring physician was notified on August 17, 2011. Physician is meeting with patient on August 19, 2011. Licensee indicated organs at risk and health effects to patient are under development.
Virginia Report ID: VA-11-08
- * * UPDATE AT 1458 EDT ON 09/02/11 FROM MIKE WELLING TO S. SANDIN * * *
The following update was received from the State of Virginia via email:
On August 31st the licensee report was received. The report indicated the cause was human error during data loading into the delivery system. An error was received and in order to clear the error the source position spacing was changed. The report detailed the licensee's dose calculations to the surrounding organs and tissue. The estimated maximum amount received by the larynx was 2.332 Gy which was 581% over the expected dose of 0.42 Gy.
A subsequent licensee response on September 1st detailed the dose to the lungs. The dose to the lungs did not differ between expected and delivered.
The patient has had two follow up visits and shows no adverse effects. A positive tumor effect was observed by the referring physician.
Notified R1DO (DiPaolo) and FSME (Hsueh).
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.