EN Revision Text: AGREEMENT STATE REPORT - INCORRECT DOSE ADMINISTRATION
The following report was received from the State of California by email:
[The] National Director Medical Physics, of McKesson Specialty Health, Radiation & Imaging, contacted LA County Radiation Management (LA County) on June 8, 2018 to report a potential Medical Event that occurred at Western Tumor Medical Group on May 9, 2018. The National Director Medical Physics has been remotely reviewing available data at their location in Decatur, Georgia, and while they are not able to definitively conclude the unplanned dose to the patient's small intestine/bowel pending the return of the Western Tumor Medical Group RSO from overseas, it appears that a Medical Event occurred.
The potential Medical Event occurred during an HDR [High Dose Rate] brachytherapy procedure in which the tandem ovoid insert shifted inside of the female patient's pelvis (which has extensive damage from uterine cancer) apparently causing two of the dwells to shift to a position different from that in the treatment plan. As a result, the dose to the non-target small intestine/bowel from the 1st of 3 fractions is believed to have been about 587 cGy (587 rad), instead of the planned approximately 220 cGy (220 rad). The treatment plan was modified for the shifted tandem ovoid position, and the 2nd and 3rd fractions were given resulting in approximately 220 cGy (220 rad) each to the small intestine/bowel.
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, including the delay in the reporting of the event by the RSO, and patient/patient's physician notification.
- * * RETRACTION FROM THOMAS GEZA TO VINCE KLCO ON 8/14/18 AT 1425 EDT * * *
The following information was received from the State of California via email:
Calculations have been performed by the Licensee's RSO that demonstrated to [the State of California] that [the dosage] fell below the reportability threshold of 10 CFR 35.3045(a)(1) and 35.3045(a)(3) because the dose occurred to the non-target organ, and only in the first of the 3 fractions, causing the numbers to even out, i.e., average down to below reportable numbers (in terms of 50 REM and 50% of planned dose).
California ID # 060818
Notified the R4DO (Deese) and NMSS Events Notifications 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.