ENS Event | |
|---|---|
07:00 Jan 5, 2012 | |
| Title | Medical Underexposure to Target Area Using High Dose Rate Afterloader Device |
| Event Description | The licensee reported that a patient received only about 10% of the required dose to the target area during a treatment for esophageal cancer. The prescribed dose for the esophageal region was 700 centigray. The area was being treated with a Varian High Dose Rate Brachytherapy Afterloader device using a 6.344 Curie Ir-192 source. The location of the source is normally tracked by a radiographically opaque image near the source. In this case, the end of the catheter also appeared somewhat radiographically opaque and was mistaken for the source location. Consequently, the source was mispositioned about 4 cm back from the intended target area resulting in the underexposure.
The physician and patient have been notified and no health effects are anticipated from the area that was unintentionally exposed due to the mispositioning of the source.
The licensee is continuing their review of this incident and have determined that the source may have been mispositioned by as much as 29 cm back from the intended target area. This may have resulted in excessive exposure to portions of the upper neck and back of the patient. A physician has scheduled an anatomical examination of the patient tomorrow to assess if there are any adverse effects related to the treatment. NRC Region IV Inspectors are currently on-site. Notified R4DO (Pick) and FSME (McIntosh). 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 | |
|---|---|
| Benefis Health Care Great Falls, Montana (NRC Region 4) | |
| License number: | 25-12710-01 |
| Organization: | Benefis Health Care |
| Reporting | |
| 10 CFR 35.3045(a)(1) | |
| Time - Person (Reporting Time:+105 h4.375 days <br />0.625 weeks <br />0.144 months <br />) | |
| Opened: | Kari Cann 16:00 Jan 9, 2012 |
| NRC Officer: | Bill Huffman |
| Last Updated: | Jan 18, 2012 |
| 47579 - NRC Website | |
Benefis Health Care with 10 CFR 35.3045(a)(1) | |
WEEKMONTHYEARENS 475792012-01-05T07:00:0005 January 2012 07:00:00
[Table view]10 CFR 35.3045(a)(1) Medical Underexposure to Target Area Using High Dose Rate Afterloader Device 2012-01-05T07:00:00 | |