ENS 51200
ENS Event | |
|---|---|
05:00 Jun 14, 2013 | |
| Title | Agreement State Report - Brachytherapy Tongue Low Dose Rate Implant Resulted in Overdose to Skin |
| Event Description | The following report was received from the Kentucky Department of Health via facsimile:
Brachytherapy LDR [low dose rate] tongue implant was loaded with thirty 1.12 mCi lr-192 sources on 6/13/13 by attending radiation oncologist. On 6/14/13 at [0730] [CDT] another physician rounded on the patient and all catheters and sources were in the proper position. At [1000] nursing on 6 East changed bedding of patient. At [1230] attending radiation oncologist rounded on patient and discovered one of the strands of sources (5 sources total) was no longer in the catheter. Physician removed nursing personnel and himself from the room and notified Physics. A Geiger counter was used to survey the room and a hot area was found in the linen basket. The linens were surveyed individually and the source was found. At [1245] the sources were reinserted into the proper catheter. Dosimetry was done to compare the plans and the deviation was well below the 20% reportable levels and almost indiscernible on the DVH [Dose Volume Histogram]. During an inspection of the medical broad scope license, RHB [Kentucky Radiation Health Branch] reviewed the above procedure and inquired as to the dose potentially received by healthy tissues, namely the skin, assuming worst the case scenario. Specifically, the lr-192 strand displaced from the catheter actually lay against the patient's skin in one location for the whole 2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br /> and 15 minutes between the time the physician last saw the strand in place and the time the patient's bed linen were changed. Based on this unrecognized worst case scenario, the RSO performed a dose calculation to the patient's skin and determined the patient may have potentially received a dose of 51.75 rem to the skin at a location which was not anticipated to receive any appreciable dose had the strands remained in place. A dose of 51.75 rem exceeds the limit requiring the report and notification of the Medical Event. A dose to the skin or an organ or tissue other than the treatment site that exceeds by five-tenths (0.5) Sv (fifty (50) rem) to an organ or tissue and fifty (50) percent or more of the dose expected from the administration defined in the written directive. The RSO at U of L [University of Louisville] e-mailed RHB a copy of the Medical Event report on July 6, 2015 at [1446]. Upon receipt of an email to the Radiation office the required 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> notification is made to the NRC Headquarters Operations Officer. The physician was notified of this potential medical event at the time of the inspection. The patient had follow up visits during and after the course of 6/14/13 treatment and was not found to be necessary to notify them of this potential event since no effects to the patient were noted. 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 | |
|---|---|
| University Of Louisville Broad Scope Medical Louisville, Kentucky (NRC Region 1) | |
| License number: | 202-029-22 |
| Organization: | Kentucky Dept Of Radiation Control |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+18058.87 h752.453 days <br />107.493 weeks <br />24.737 months <br />) | |
| Opened: | Curt Pendergrass 15:52 Jul 6, 2015 |
| NRC Officer: | Jeff Herrera |
| Last Updated: | Jul 6, 2015 |
| 51200 - NRC Website | |
University Of Louisville Broad Scope Medical with Agreement State | |
WEEKMONTHYEARENS 512002013-06-14T05:00:00014 June 2013 05:00:00
[Table view]Agreement State Agreement State Report - Brachytherapy Tongue Low Dose Rate Implant Resulted in Overdose to Skin 2013-06-14T05:00:00 | |