ENS 53350
ENS Event | |
|---|---|
06:00 Mar 8, 2018 | |
| Title | Patient Received Dose Less than Prescribed Dose |
| Event Description | The following was received from the licensee via email:
On March 8, 2018 and March 12, 2018, the patient was treated with the incorrect setup. On March 15, 2018, the patient was treated with the correct setup. Following the third treatment, both physicists were in the HDR [High Dose Rate] vault. The patient's setup was still on the treatment table, the physicist who had delivered the first two treatments noticed the accuform in the setup. At this time the patient had already left the facility. His next treatment was scheduled for March 19, 2018. This was discussed with the physician and the decision was made to perform a CT without the accuform, prior to the next treatment. The plan was recreated, using the same dwell weights and positions as the original plan. At this point we discovered that the patient had been under-dosed by more than 50 percent. Physics notified the NRC and the prescribing physician. As a result of the misadministration discovered March 19, 2018, a root cause analysis was performed. The direct cause of the incident was the failure to properly recreate the initial patient setup. The exclusion of the accuform caused the patient's head to be in the wrong position, leaving a gap between the treatment device and the patient's skin. Contributing factors include the lack of a specific policy regarding custom immobilization in HDR procedures, this was only the second brachytherapy patient using custom immobilization, the pictures from the simulation did not completely show the accuform, and it is generally a therapist, not a physicist, who reproduces the daily setup using custom immobilization. Items identified during root cause analysis: 1. At the time of treatment, there was not a policy specifically written for skin brachytherapy 2. The accuform was not used in the patient setup 3. The pictures from the simulation did not completely show the custom setup. 4. At the time of the incident there was not a verification system in place, to track the items needed for each custom setup. Corrective actions: 1. A policy was created and provided to [NRC R4 (Simmons)] on April 4, 2018. 2. Our new policy ensures that a therapist will be present at the first treatment, and any time a physicist is treating the patient for the first time. 3. In the CT simulation, any custom immobilization used in brachytherapy will be photographed with and without the patient. This will ensure that each piece of the custom device can be clearly visualized. Our IT department will be installing a computer monitor, keyboard and mouse in the HDR treatment vault. This will allow the verification of the setup notes and photographs in the treatment room. 4. Physics is working with our IT department and Elekta to implement a bar code scanning system to track custom setup devices. 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 | |
|---|---|
| Rapid City Regional Hospital Rapid City, South Dakota (NRC Region 4) | |
| License number: | 40-00238-04 |
| Organization: | Rapid City Regional Hospital |
| Reporting | |
| 10 CFR 35.3045(a)(1) | |
| Time - Person (Reporting Time:+1039.08 h43.295 days <br />6.185 weeks <br />1.423 months <br />) | |
| Opened: | James Mckee 12:05 Apr 20, 2018 |
| NRC Officer: | Dong Park |
| Last Updated: | Apr 20, 2018 |
| 53350 - NRC Website | |
Rapid City Regional Hospital with 10 CFR 35.3045(a)(1) | |
WEEKMONTHYEARENS 532732018-03-08T06:00:0008 March 2018 06:00:00
[Table view]10 CFR 35.3045(a)(1) Medical Event Involving Delivered Dose 50 Percent Less than Prescribed Dose ENS 533502018-03-08T06:00:0008 March 2018 06:00:00 10 CFR 35.3045(a)(1) Patient Received Dose Less than Prescribed Dose ENS 488762013-02-26T06:00:00026 February 2013 06:00:00 10 CFR 35.3045(a)(1) Medical Event Involving Delivered Dose Exceeding Prescribed Dose >20% 2018-03-08T06:00:00 | |