The following report was received from the
Pennsylvania Department of Environmental Protection Bureau of Radiation Protection via email:
The licensee reported that on February 8, 2019, while reviewing a patient treatment plan, it was discovered that the patient had received a dose from a high dose rate remote afterloader containing iridium-192 that was less than the prescribed dose in the written directive. The original treatment plan was prescribed for 7.0 Gy per fraction, however at the beginning of the 3rd fraction it was noticed that the total dose delivered was 4.67 Gy instead of the prescribed 14 Gy they should have received for the same 2 fractions. The physician has informed the patient and will amend the written directive to add additional fractions at different doses to achieve the original prescribed dose to the treatment area. No more information is available at this time from the licensee. We will update this event as soon as more information is provided.
Cause of the Event: Unknown / Human error.
ACTIONS: The Department [Pennsylvania Department of Environmental Protection] will perform a reactive inspection. More information will be provided upon receipt."
- * * UPDATE AT 1227 EST ON 02/14/2019 FROM JOHN CHIPPO TO TOM KENDZIA * * *
The following update was received from the Pennsylvania Department of Environmental Protection via email:
The patient received treatment on January 29, 2019, and February 5, 2019. The patient had not finished her initially scheduled 3rd fraction. The Medical Event was identified on Friday, February 8, 2019. The equipment manufacturer is Varian, model VariSource iX(t), Serial Number 00400. The source activity as of February 11, 2019 was 6.819 Ci. The licensee is still in the process of identifying root cause and corrective action.
Pennsylvania Report: PA190003
Notified the R1DO (Ferdas) and NMSS Events (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.