ENS Event | |
|---|---|
05:00 Aug 22, 2013 | |
| Title | Agreement State Report - Therapy Dose Applied to Wrong Location |
| Event Description | The following report was received via e-mail from the Louisiana Department of Environmental Quality:
On 08/27/2013, the RSO for Tulane University Hospital called to notify the Department that their facility had a Medical Event involving [exposure to unintended tissue greater than] 50 Rem. The event was discovered on 08/27/2013 when an application was not able to be applied to the intended tissue. The HDR source had 'dog legged' into the bowel area when it was intended to apply the radiation dose to the cervical area. The films were pulled for the application on 08/22/2013 and revealed that the application had 'dog legged' also. The cervical tissue did not receive the initial intended dose. The HDR [High Dose Rate Brachytherapy Afterloader] unit was a Nucletron Micro-Selectron, loaded with [an] Ir-192 [source]. The therapy dose was 8.4 Gray [840 rads] given in fractions. The patient is to receive the entire corrected therapy dose prescribed. This is believed to be (under investigation) a positioning problem and not an equipment malfunction. The patient's physician has been notified. However, the patient was heavily sedated and has not been notified. Updates will be made when additional information is available. Louisiana Report ID: LA-130001 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 | |
|---|---|
| Tulane University Hospital New Orleans, Louisiana (NRC Region 4) | |
| License number: | LA-3325-LO1 |
| Organization: | Louisiana Radiation Protection Div |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+133 h5.542 days <br />0.792 weeks <br />0.182 months <br />) | |
| Opened: | Joe Noble 18:00 Aug 27, 2013 |
| NRC Officer: | Bill Huffman |
| Last Updated: | Aug 27, 2013 |
| 49310 - NRC Website | |
Tulane University Hospital with Agreement State | |
WEEKMONTHYEARENS 493102013-08-22T05:00:00022 August 2013 05:00:00
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