ENS Event | |
|---|---|
04:00 Mar 4, 2014 | |
| Title | Agreement State Report - Misadministration of Iodine-125 Solution During Brachytherapy |
| Event Description | The following information was received via facsimile:
A patient was prescribed 50 Gray to be delivered to a brain tumor bed via a GliaSite balloon inflated with 200 mCi of I-125 saline solution implanted for 66 hours7.638889e-4 days <br />0.0183 hours <br />1.09127e-4 weeks <br />2.5113e-5 months <br />. Upon removal of the balloon on March 7, 2014, it was discovered that the balloon had not inflated and no dose to the tumor bed had been delivered. A three position stopcock was incorrectly positioned at the time of inflation and the I-125 saline solution was diverted to another syringe rather than to the balloon. All material is accounted for and is being held for DIS. The three position stopcock is not part of the vendor's kit. Corrective Actions: In-service by the vendor scheduled, revision of policies and procedures to include verification of balloon via medical imaging post-infusion, and in-service to staff on new policies and procedures. NYS Incident: #1054 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 | |
|---|---|
| Confidential Confidential, New York (NRC Region 1) | |
| License number: | CONFIDENTIAL |
| Organization: | New York State Dept. Of Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+373.05 h15.544 days <br />2.221 weeks <br />0.511 months <br />) | |
| Opened: | Fax 16:03 Mar 19, 2014 |
| NRC Officer: | Donald Norwood |
| Last Updated: | Mar 19, 2014 |
| 49931 - NRC Website | |
Confidential with Agreement State | |
WEEKMONTHYEARENS 499312014-03-04T04:00:0004 March 2014 04:00:00
[Table view]Agreement State Agreement State Report - Misadministration of Iodine-125 Solution During Brachytherapy 2014-03-04T04:00:00 | |