EN Revision Text: AGREEMENT STATE REPORT -
BRACHYTHERAPY SOURCE
DID NOT FULLY RETRACT
The following was received from the State of California via E-mail.
The Regional RSO, Kaiser Permanente Medical Care Program, contacted LA County Radiation Management (LA County) on April 10, 2018 to report a Medical Event that occurred at the Kaiser Therapy Department on March 28, 2018 located in Los Angeles, CA. The event occurred during a HDR [High-Dose Rate] brachytherapy procedure in which the iridium-192 (Ir-192) source did not fully retract post-treatment and remained in the transfer guide tube about 5 cm from the cylinder-transfer guide tube connector. The source remained in this position between the patient's thighs for approximately 15 minutes resulting in the patient receiving about 300 cGy (300 rad) to the thighs. It was later determined that the source wire was bent near the source which is suspected to be the reason the source did not retract fully.
A site visit will be conducted to meet with the licensee's personnel when the RSO comes back from travel to gain a better understanding of the details of the event, especially concerning the delay in removing the source from the immediate vicinity of the patient, the delay in reporting the event to the RSO, as well as to better understand the reason the source wire did not fully retract.
California 5010 Number: 041018 (5010#)
- * * UPDATE ON 7/30/2018 AT 1746 EDT FROM ANA CASAJE TO ANDREW WAUGH * * *
The following was excerpted from an E-mail received from the State of California:
Kaiser Permanente contacted LA County Radiation Management on April 24, 2018 to update this medical event based on new information submitted by their primary medical physicist and corroborated by other HDR personnel present during the incident. The patient's exposure time has been revised from 15 minutes to 5 minutes, and the calculated unintended dose was revised from 300 cGy to 100 cGy.
Notified R4DO (Gaddy) and NMSS (Bollock) and NMSS Events Notification group 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.