ENS 53501
ENS Event | |
|---|---|
05:00 Jul 10, 2018 | |
| Title | Agreement State Report - Medical Event |
| Event Description | The following was received from the State of Texas via E-mail:
On July 11, 2018, a license notified the Agency [Texas Department of State Health Services] that a medical event had occurred. On July 10, 2018, a patient received the first fraction of a treatment plan delivered by a high dose rate afterloader (HDR) utilizing iridium-192. On July 11, 2018, the medical physicist noticed that the dose per fraction entered in the treatment plan of the 1st fraction was incorrect. Instead of a 350 cGy/fraction for 6 fractions, a value of 2100 cGy was entered for one fraction (which was the total dose for the brachytherapy course). The Radiation Oncologist (RO) was notified and he notified the referring physician and patient that day. RO will follow the patient closely and make all possible interventions to minimize potential adverse effects. The Agency is awaiting answers to multiple questions including identification of target area. More information will be provided as it is obtained and in accordance with SA-300. Texas Incident #: I-9594
The following was received from the State of Texas via E-mail: The patient was treated for vaginal cancer using HDR (High Dose Rate) brachytherapy using a 6 Curie Iridium-192 source. A written report was received from the licensee indicating several factors contributed to the medical event including a busy work day, mental fatigue, verbal description of the intended dose instead of written direction, and unavailability of another medical physicist (MP) to independently review the dose/fraction entered in the treatment planning system. The overall brachytherapy plan was modified and the volume treated in the first fraction was considered completed and [the patient] will not receive further treatment. The Radiation Oncologist will follow the patient closely and make all possible interventions to minimize potential adverse effects. Immediate changes implemented at the facility include: no HDR treatment will start without a written prescription in the patient electronic medical record and an independent check of the prescription entry and radiation dosimetry will be conducted by an Authorized User, other than the MP who generated the treatment plan. An Agency team will conduct an onsite investigation in early August 2018 when all parties involved are available. Additional information will be provided as it is obtained and in accordance with SA-300. Notified R4DO (Pick) and NMSS Events Notification E-mail group. 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 | |
|---|---|
| Central Texas Medical Specialists Pllc Austin, Texas (NRC Region 4) | |
| License number: | L 06618 |
| Organization: | Texas Dept Of State Health Services |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+34.97 h1.457 days <br />0.208 weeks <br />0.0479 months <br />) | |
| Opened: | Chris Moore 15:58 Jul 11, 2018 |
| NRC Officer: | Steven Vitto |
| Last Updated: | Jul 13, 2018 |
| 53501 - NRC Website | |
Central Texas Medical Specialists Pllc with Agreement State | |
WEEKMONTHYEARENS 535012018-07-10T05:00:00010 July 2018 05:00:00
[Table view]Agreement State Agreement State Report - Medical Event 2018-07-10T05:00:00 | |