ENS 51299
ENS Event | |
|---|---|
04:00 Aug 5, 2015 | |
| Title | Georgia Agreement State Report - Medical Event Due to Overexposure |
| Event Description | The following information was provided by the State of Georgia via email:
The [Georgia] Radioactive Materials Program received a call on Aug 7, 2015 that a medical event occurred in the radiation oncology department at Wellstar Kennestone Hospital on August 5, 2015. The event was found out 2 days later when the physicist was reviewing the patient's records on Aug 7, 2015. Patient was being treated for cervical cancer (T&O implant) using the HDR (Ir-192, 5 Ci) . The authorized user had prescribed a treatment plan and then changed it to a reduced dose by 1/3 for 3 fractions. The first 2 fractions the patient received the reduced dose. On the third fraction, the 1st plan was delivered. The total dose delivered exceed the prescribed dose by [greater than] 20 percent and the fractionated dose delivered differs from the prescribed dose by more than 50 percent. The authorized user determined no harm came to the patient. The authorized user will be informing the patient on August 7, 2015. The dose delivered on the 3rd fraction was 900 cGy and for the T&O implant, the total dose received for all 3 fractions was 1500 cGy.
The following information was received via e-mail: First fraction delivered was 300 cGy Second faction delivered was 300 cGy Third fraction delivered was 900 cGy, should have been 300 cGy Total dosed received 1500 cGy On August 4, 2015, the patient received the first fraction. The physicist confirmed with the AU [Authorized User] that the plan was 900 cGy , 3 fractions and began the treatment. The dwell time for each fraction for the first plan was 1128.4 sec. After realizing how much dose was being delivered to the patient, the AU ordered to stop the treatment 219 sec into the treatment. A new written directive was prepared for 300 cGy per fraction, 900 cGy total. The first fraction continued to be delivered with the second plan. The total volume treated with the first plan was subtracted out from the seconded plan. The first two fractions the patient received the correct amount (300 cGy). On August 7, 2015, the patient was scheduled to receive her third fraction. When the patient's chart is pulled up on the computer console, both plans are displayed, the first plan and the second plan. The first plan auto defaults as the current plan being used. The physicist accidently used the initial plan (900 cGy/fraction) for the third fraction. It wasn't until August 7, 2015 when the physicist was reviewing the patients chart when she realized the first plan was delivered on the third fraction. The dwell time for each fraction should have been 350 sec. However, the dwell time for the third fraction was 1128 sec. The authorized user determined no harm came to the patient. The authorized user will be informing the patient on August 8, 2015. Notified the R1DO (Powell) and NMSS Events Resource (via e-mail). 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 | |
|---|---|
| Wellstar Kennestone Hospital Marietta, Georgia (NRC Region 1) | |
| License number: | GA 328-1 |
| Organization: | Georgia Radioactive Material Pgm |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+59.97 h2.499 days <br />0.357 weeks <br />0.0821 months <br />) | |
| Opened: | Irene Bennett 15:58 Aug 7, 2015 |
| NRC Officer: | Jeff Rotton |
| Last Updated: | Aug 11, 2015 |
| 51299 - NRC Website | |
Wellstar Kennestone Hospital with Agreement State | |
WEEKMONTHYEARENS 568812023-12-07T05:00:0007 December 2023 05:00:00
[Table view]Agreement State Medical Misadminstration ENS 512992015-08-05T04:00:0005 August 2015 04:00:00 Agreement State Georgia Agreement State Report - Medical Event Due to Overexposure 2023-12-07T05:00:00 | |