ENS 51252

v t e ENS Event
04:00 Jul 1, 2015
Title	Agreement State Report - Vaginal Catheter Slipped During Treatment
Event Description	The following report was received via e-mail: An incident has come to light at [the licensee's] Conyers clinic. A patient was treated with a vaginal cylinder at the beginning of July, 2015. The treatment was delivered in 3 fractions. On a recent follow-up exam, the patient presented with a single mark on the skin of the upper inner thigh on both legs. The radiation oncologist felt these marks were consistent with radiation dermatitis. A review of the patient's treatment plan and treatment records showed no errors had occurred. [The licensee's] current thinking is that the only plausible explanation is that the catheter which contains the source wire was not securely locked inside the vaginal cylinder and partially slipped out during treatment.. If this occurred, the most proximal dwell position could have fallen on the skin of the upper thigh. [The Georgia Radioactive Materials Program] is continuing to investigate. 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.

ENS 51252 +/-
Where
Radiotherapy Clinics Of Georgia Conyers, Georgia (NRC Region 1)
Organization:	Georgia Radioactive Material Pgm
Reporting

Agreement State
Time - Person (Reporting Time:+515.33 h21.472 days <br />3.067 weeks <br />0.706 months <br />)
Opened:	Travis Cartoski 15:20 Jul 22, 2015
NRC Officer:	Mark Abramovitz
Last Updated:	Jul 22, 2015
51252 - NRC Website
v • d • e

v t e Emergency Notification System
Radiotherapy Clinics Of Georgia with Agreement State
WEEKMONTHYEAR2015-07-17T04:00:00 [Table view]
[ENS list for Radiotherapy Clinics Of Georgia]

Navigation menu