The following information was received from the State of
Maine via email:
Maine General Medical Center reported that a patient received less dose than prescribed to the treatment site and dose to an unintended site during HDR (Varian model GammaMed Plus) brachytherapy using an Ir-192 source. The patient was prescribed to receive a 1,350 cGy (rad) boost dose to the vaginal cuff in three weekly fractions of 450 cGy (rad) each. The first fraction was delivered on 2/25/2015 using a 3.5-cm applicator. Post insertion CT images were reviewed by the physician and the first fraction was delivered correctly. During the second fraction on 3/4/2015, a second physician was unable to insert the 3.5-cm applicator due to edema and tenderness. A new treatment plan was developed to deliver the prescribed 450 cGy (rad) dose using a 2.6-cm applicator. Upon review of the previous week's images, the second physician noted that the applicator was approximately 7 cm short of the intended position such that the tip of the applicator did not contact the vaginal cuff. On 3/11/2015, a fraction was correctly delivered using the 2.6-cm applicator. The second physician reviewed the treatment deviation with the patient and recommended that an additional fraction of 450 cGy (rad) be administered, which was scheduled for 3/18/2015. The cause was determined to be human error.
This event was reported to the State of Maine on 03/11/2015. An NMED report was submitted on 03/12/2015 [NMED Item Number: 150165].
Maine Report Nr.: ME150002 and ME150002A
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.