ENS 49643
ENS Event | |
|---|---|
05:00 Dec 16, 2013 | |
| Title | Agreement State Report - Possible Medical Misadministration |
| Event Description | The following report was received via email:
Description of Event: [The Georgia Department of Natural Resources] Received a call from the RSO [Radiation Safety Officer] of RCG [Radiotherapy Clinics of Georgia] on December 17, 2013 at 0930 EST, informing the Department of a possible misadministration that occurred at the Snellville location. The wrong [High Dose Rate] HDR treatment plan was selected and used on a patient resulting in some possible injury to the patient. An investigation is currently being initiated to determine the cause and effects of the error. The licensee will provide an official report to the Department within 15 days. Georgia Incident Number 121613.
[The Georgia State Investigator] received the initial call on 12/17/2013 at 0930 EST. The incident regarded an Ir-192 HDR afterloader and had occurred on 12/16/2013. . [The initial report stated:] It was determined that the wrong treatment plan was given and a misadministration had occurred. The correct site and applicator were used; however, a gynecological treatment plan ran in place of the intended skin treatment plan. No symptoms were evident at this time, but the patient was alerted to look for a reddening of the skin. The RSO did not communicate much information and left many details open until they could submit the final report. [The Georgia State Investigator] forwarded this information to the [NRC] upon documenting it. [A Georgia State Investigator] performed a reactive site [follow-up] inspection on 12/18/2013 to discern more information about the incident. One of the contributing causes appears to be similar last names on the two patient plans. No other verification of the treatment plans seemed to be conducted other than selecting the name; which the physicist inadvertently clicked on the wrong patient name in this selection process. 113 seconds passed before the error was caught and the physicist pressed for manual interrupt of the treatment. The treatment was intended for the skin on the temporal region of the patient's head. This used a skin plaque type applicator. Instead, a gynecological plan ran in the system but with the skin plaque applicator in place on the correct location of the patient. The error caused the Ir-192 source to hit a dead end at the first channel due to it having a shorter channel length than the other plan anticipated. From what the physicist could determine it was stuck in that position for nearly the entire time. The prescribed procedure was for 40 (4000 rem) Gy to be delivered in a fractionated schedule. An actual delivered dose is yet to be calculated and will determine whether a corrective fractionation schedule will be prescribed to correct for this since most of the dose was deposited in the vicinity of the treatment site. This determination will be included in the final report. At this time, the only expected acute effects to the patient may be reddening of the skin in the immediate location of the source. The source had an 8.0 Ci Ir-192 source from Alpha Omega Services, Inc. (Serial#: 24-01-2470-001-110113-12043-45). This was in a mobile HDR unit made by Varian (Model: Gamma Med(+)iX / Serial#: H640510-GM). Corrective actions are still being discussed and will be clearly identified in the final report to prevent future occurrences. Notified the R1DO (Dimitriadis), FSME Events Resource and FSME (McIntosh) via email only. 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 | |
|---|---|
| Radiotherapy Clinics Of Georgia Snellville, Georgia (NRC Region 1) | |
| License number: | GA 848-5 |
| Organization: | Georgia Radioactive Material Pgm |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+33.32 h1.388 days <br />0.198 weeks <br />0.0456 months <br />) | |
| Opened: | Kit Ramdeen 14:19 Dec 17, 2013 |
| NRC Officer: | Daniel Mills |
| Last Updated: | Dec 18, 2013 |
| 49643 - NRC Website | |
Radiotherapy Clinics Of Georgia with Agreement State | |
WEEKMONTHYEARENS 512512015-07-17T04:00:00017 July 2015 04:00:00
[Table view]Agreement State Agreement State Report - Medical Overdose for Skin Cancer ENS 512522015-07-01T04:00:0001 July 2015 04:00:00 Agreement State Agreement State Report - Vaginal Catheter Slipped During Treatment ENS 496432013-12-16T05:00:00016 December 2013 05:00:00 Agreement State Agreement State Report - Possible Medical Misadministration 2015-07-17T04:00:00 | |