ENS Event | |
|---|---|
07:00 May 27, 2016 | |
| Title | Agreement State Report - Brachytherapy Underdose |
| Event Description | The following was received from the State of California via email:
The RSO [Radiation Safety Officer] of Loma Linda Medical Center notified the RHB [Radiologic Health Branch] Brea ICE [Inspection, Compliance and Enforcement] office that they believe a medical event occurred on Friday, May 28, 2016. A patient was admitted to the hospital for treatment of carcinoma. The treatment plan involved [10 CFR] 35.400 use of Cs-137 sealed sources for brachytherapy with a tandem and ovoid applicator. The patient's written directive called for 3,460 cGy to target area A (left side tandem), but only approximately 1,500 cGy was delivered. The lower rectum and vaginal areas received more than expected dose, but is believed to be within tolerance. Critical organs of bladder and mid-rectum also received less than expected incidental exposure. The cause of the under dose was human error. The applicator tube used to place the source into the tandem had become crimped by the lead pig during transport to the patients room. During application by the resident physician and medical physicist, the resistance felt during the application process lead them to believe the source was fully deployed to the end of the tube. The chief physicist notified the RSO on Tuesday, May 31, 2016 at 1630 pm, of his dose calculations, in which the hospital began medical event notifications. 5010 Number: 060216 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 | |
|---|---|
| Loma Linda Medical Center San Bernardino, California (NRC Region 4) | |
| License number: | 0060-36 |
| Organization: | California Radiation Control Prgm |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+157.37 h6.557 days <br />0.937 weeks <br />0.216 months <br />) | |
| Opened: | John G. Fassell 20:22 Jun 2, 2016 |
| NRC Officer: | Dong Park |
| Last Updated: | Jun 2, 2016 |
| 51973 - NRC Website | |
Loma Linda Medical Center with Agreement State | |
WEEKMONTHYEARENS 550842021-01-25T08:00:00025 January 2021 08:00:00
[Table view]Agreement State Incorrect Dose Delivered to Patient ENS 528902017-08-04T07:00:0004 August 2017 07:00:00 Agreement State Agreement State Report - Y-90 Treatment Underdose ENS 519732016-05-27T07:00:00027 May 2016 07:00:00 Agreement State Agreement State Report - Brachytherapy Underdose ENS 483892012-05-23T07:00:00023 May 2012 07:00:00 Agreement State Agreement State Report - Potential Medical Event ENS 405942004-03-16T08:00:00016 March 2004 08:00:00 Agreement State Agreement State Report - Missing Sr-90 Eye Applicator Source 2021-01-25T08:00:00 | |