ENS 48085
ENS Event | |
|---|---|
04:00 Jul 10, 2012 | |
| Title | Wrong Applicator Used in Procedure Preventing Patient from Receiving Proper Dose |
| Event Description | The RSO received a phone call from the physicist who explained she incorrectly connected the HDR unit during a patient treatment. She explained how she connected a transfer tube to the endobronch catheter, when she should have connected the endobronch catheter directly to the HDR unit. This would add about 1 meter of distance between the intended treatment site and the HDR unit source.
It was determined that the source exited the HDR unit, but never made it to the patient. This was confirmed by a repeat test/reproduction with a dummy patient/setup in the exact format the patient treatment was performed. It was clear from observing this set up a mistaken addition of about 1 meter of transfer tube was added and that the source did not make it to the patient treatment site, or to the patient at all, and instead would be within the endobronch catheter potentially exposing a portion of patient skin (confirmed not to be in direct skin contact). We then placed a farmer chamber, a MOSfet and an Ion chamber in locations where we determined would be the highest possible patient skin dose measurements. We determined the highest potential skin dose to be 1.8cGy/1.8rem (significantly below the 50rem medical event definition) to the patient arm/shoulder area, however due to a folded blanket that was placed in that location it prevented direct skin contact. The hospital staff has changed policy as of today, to include a time out for the physicist to verbally voice the assurance to the in room nurse of proper connection to the HDR unit. They are planning an education process for their nursing staff so they may visually assist as a secondary visual confirmation. They are also reassessing additional support staff to be present during HDR treatment in a future meeting. The RSO believes the error happened due to human error, and a rushed procedure that occurred at the end of the day. The hospital staff is assessing the patient for potential skin burns both now and in the future (2wk, 5wks for reassessment). They do not expect to see skin burns, but will perform this patient skin burn assessment for assurance and to confirm our lower dose skin estimates. They intend on completing the patient treatment and therefore will complete this written directive dose which was scheduled for 500cGy, based upon the medical consult with the Radiation Oncologist. We are in process of follow-up with the patient, and referring physician." 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 | |
|---|---|
| St Johns Macomb Oakland Hospital Warren, Michigan (NRC Region 3) | |
| License number: | 21-01190.05 |
| Organization: | St Johns Macomb Oakland Hospital |
| Reporting | |
| 10 CFR 35.3045(a)(1) | |
| Time - Person (Reporting Time:+12.27 h0.511 days <br />0.073 weeks <br />0.0168 months <br />) | |
| Opened: | Laura Smith 16:16 Jul 10, 2012 |
| NRC Officer: | John Knoke |
| Last Updated: | Jul 10, 2012 |
| 48085 - NRC Website | |
St Johns Macomb Oakland Hospital with 10 CFR 35.3045(a)(1) | |
WEEKMONTHYEARENS 480852012-07-10T04:00:00010 July 2012 04:00:00
[Table view]10 CFR 35.3045(a)(1) Wrong Applicator Used in Procedure Preventing Patient from Receiving Proper Dose 2012-07-10T04:00:00 | |