The following report was received from the State of
Illinois via email:
On March 25, 2015, Agency [Illinois Emergency Management Agency] representatives were advised via voicemail message by a medical physicist associated with the licensee's facility that a medical event had occurred at a point in the past. The medical physicist had been conducting a retrospective review of cases performed at the site which were similar to another case that had resulted in a medical event at another facility.
The review included all 5 cases performed at the licensee's facility since August of 2013 when treatments were first started. The treatment protocols involved using a Strut Adjusted Volume Implant (SAVI) catheter, a Nucletron high dose rate afterloader and the Oncentra treatment planning system which was also used in the similar situation. They determined that at least one of the treatments conducted March 10-14, 2014, involved an error of greater than 20 percent which would meet the criteria of a medical event and dose to an unintended organ exceeding 50 rem.
On March 26, 2015, a radiation oncologist from the licensee contacted the Agency with information to confirm the medical event. The patient had been treated twice a day for five days for a total intended V95 dose of 34 Gy in ten equal fractions. The target only received 43 percent of the intended dose with the majority instead being delivered to the catheter insertion site (approximately 30 Gy). It was determined that although the patient had later returned on June 24, 2014, with pain and redness at the incision site of the left breast, the cause of damage to the 21 cc tissue area was not attributed to radiation damage. The patient was referred to their surgeon who excised the affected area during an outpatient procedure.
The licensee has suspended treatments using the protocol pending a full investigation and evaluation of appropriate corrective measures to prevent a recurrence by a physicist not associated with the treatments. The Agency is conducting its own investigation as well. This matter remains open at this time.
This event strongly parallels that of an event which the State of Illinois reported on February 13, 2015, see EN#50818.
Illinois State Item Number: IL15009
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.