The following information was received via E-mail:
The licensee reported on November 17, 2016 that the licensee administered on November 16, 2016 to a patient a first fraction dose of 1100 centigray to the vagina instead of the prescribed first fraction dose of 600 centigray to the vagina.
This dose was the first of three fractionated doses, the second and third fractionated doses have not yet been administered. Each fractionated dose was prescribed to be 600 centigray for a total dose of 18 gray (1,800 centigray).
The licensee used a Varian Medical Systems, Inc. GammaMed plus iX High Dose Rate (HDR) remote afterloader unit containing 7 curies of iridium-192 to deliver the dose.
This is a reportable medical event in accordance with 105 CMR 120.594(A)(1)(a)3.
The licensee reported that the patient and the referring physician have been notified and that no harmful effect to the patient has been reported.
The licensee reported that the event occurred because the physician's plan was not performed as prescribed in the written directive and that no other cause was known at time of report.
The Agency (Massachusetts Radiation Control Program) Director requested the licensee to cease HDR use until a corrective action to prevent recurrence has been implemented.
The Agency plans to perform a special inspection and considers this event to be open.
- * * RETRACTION FROM JOSHUA DAEHLER TO JOHN SHOEMAKER AT 1506 EST ON 01/12/17 * * *
The Agency is retracting this medical event. This is not a reportable event.
Based upon inspection/review by the Agency with the licensee, it was determined that each of the three fractions was actually prescribed to be 700 centigray for a total dose of 2,100 centigray to the vagina. The first fraction dose of 700 centigray was successfully administered to the vagina. The two additional fraction doses of 700 centigray each were also successfully administered to the vagina. The licensee prematurely reported the issue without having all the facts and without review by the RSO. Subsequently to review of information available to the licensee it was determined no reportable event occurred.
Notified R1DO (Dimitriadis) and NMSS_Events_Notification via email.
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.