ENS Event | |
|---|---|
05:00 Feb 15, 2016 | |
| Title | Agreement State Report - Medical Misadministration |
| Event Description | The following report was received from the State of Georgia via email:
The following was reported to the State of Georgia on February 15, 2016. The patient was prepped for the delivery of doses of 18 and 21 Gy to 14 subcentimeter brain metastases with Gamma Knife stereotactic radiosurgery. The frame adapter was placed on the patient's stereotactic head frame by a Gamma Knife trained registered nurse, supervised by Authorized Medical Physicist [AMP], and Authorized User [AU]. After five of the planned 14 lesions were treated, the patient was given a break in order to use the restroom and for additional medication. During this treatment break, the AU and AMP entered the room to release the patient from the restraining device and assist [the patient] to the rest room. It was at that point that it was discovered that the restraining device was locked, but not in the correct position. The displaced distance was measured and determined to be a maximum discrepancy of 2 cm in one plane. The AMP and AU applied the displacement to the treatment plan to determine which areas were treated and which were not. It was determined that a potential misadministration had occurred. The RSO [Radiation Safety Officer] was notified to discuss the course of action. Following discussions with the AMP, AU, the medical director, the prescribing physician and radiation safety officer, it was decided that there was a potential medical event or misadministration as defined in 391-3-17-.05(115)(a)3 or 391-3-17-.05(115)(b). The cause of the event is uncertain at this time. The head restraining device should not have been able to be secured unless it was in the proper position. An investigation is ongoing and additional information is being sought. The patient received an unintended radiation dose to normal brain tissue, however, it was determined by the authorized user in consult with the medical physicist that little clinical effect will be demonstrated due to this inadvertent exposure. The patient, the patient's family and the patient's referring physician were informed of the event. After extensive discussions, it was agreed by all parties that the treatment would be completed to ensure that the correct dose is delivered to the remaining target areas. This is all the data available at the moment. A reactive inspection is currently underway and updates are soon to follow. 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 | |
|---|---|
| St Joseph'S Hospital Atlanta, Georgia (NRC Region 1) | |
| License number: | GA 296-6 |
| Organization: | Georgia Radioactive Material Pgm |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+3.78 h0.158 days <br />0.0225 weeks <br />0.00518 months <br />) | |
| Opened: | Travis Cartoski 08:47 Feb 15, 2016 |
| NRC Officer: | John Shoemaker |
| Last Updated: | Feb 15, 2016 |
| 51735 - NRC Website | |
St Joseph'S Hospital with Agreement State | |
WEEKMONTHYEARENS 517352016-02-15T05:00:00015 February 2016 05:00:00
[Table view]Agreement State Agreement State Report - Medical Misadministration 2016-02-15T05:00:00 | |