ENS Event | |
|---|---|
05:00 Jan 5, 2012 | |
| Title | Agreement State Report - Medical Radiation Treatment Exposure to Wrong Treatment Site |
| Event Description | The following report was received from the State of North Carolina via email:
A cancer patient undergoing therapeutic radiation treatment for gastric cancer received an exposure to the wrong treatment site. This error occurred using a HDR afterloader device with a radioactive source containing Ir-192. The event occurred after the dosimetrist made an error while correcting a change to dwell position due to catheter migration. The dwell position was mistakenly adjusted out rather than in. Two treatments were made prior to the error being detected. The error resulted in an approximately 4 cm positioning error, which caused the source to stop short of the target so that the total prescribed dose was not delivered. The patient was informed of the event, and received a correct third treatment as well as external beam therapy. Additional information will be provided as it is provided by the licensee. The intended treatment site was a bile duct which was to receive 700 cGy in three (3) fractions. The first two (2) fractions were delivered on 1/5/2012 and 1/12/2012 with the source mispositioned as indicated above. The Regional Inspector for the State of NC is following up. 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 | |
|---|---|
| Presbyterian Hospital Charlotte, North Carolina (NRC Region 1) | |
| License number: | 060-0019-6 |
| Organization: | Nc Div Of Radiation Protection |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+443.7 h18.488 days <br />2.641 weeks <br />0.608 months <br />) | |
| Opened: | Henry Barnes 16:42 Jan 23, 2012 |
| NRC Officer: | Steve Sandin |
| Last Updated: | Jan 23, 2012 |
| 47616 - NRC Website | |
Presbyterian Hospital with Agreement State | |
WEEKMONTHYEARENS 476162012-01-05T05:00:0005 January 2012 05:00:00
[Table view]Agreement State Agreement State Report - Medical Radiation Treatment Exposure to Wrong Treatment Site 2012-01-05T05:00:00 | |