ENS 54136

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v t e ENS Event
04:00 Jun 26, 2019
Title	Agreement State Report - Brachytherapy Underdose Due to Dislodging of Device
Event Description	The following was received via e-mail: A patient was planned for a HDR [high dose rate] brachytherapy vaginal cuff treatment, fraction 1 of 2, at 5 Gy per fraction. A vaginal cylinder was placed in the vaginal canal and the positioning was verified with a cone beam CT scan. The cylinder was then connected to the afterloader containing the Ir-192 source [3.449 Ci; GammaMed 232 S/N: 24-01-7273-001-020819-12601-99] and treatment commenced. Upon completion of the treatment, it was observed that the vaginal cylinder was dislodged from the initial position. The cylinder was found between the legs, outside the vaginal canal, in contact with the perineal region. The patient indicated that she had coughed at some point during the treatment, which may have contributed to the dislodgement of the cylinder. The estimated skin dose is 5 Gy (500 rad). No erythema was observed at the time of discovery. The patient and referring physician have been notified. Ohio Item Number: OH190009 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. * * RETRACTION ON 7/17/19 AT 1342 EDT FROM MICHAEL RUBADUE TO HOWIE CROUCH * * * The following retraction information was obtained from the state of Ohio via email: An inspection was conducted on July 15, 2019 to investigate the event. It was determined that the applicator was properly secured for the prescribed treatment, but was dislodged by the patient. Since the cause was patient intervention, this is not a medical event. Notified R3DO (Edwards) and NMSS Events Notification (email).

ENS 54136 +/- *RETRACTED*
Where
The Cleveland Clinic Foundation Sandusky, Ohio (NRC Region 3)
License number:	02230220000
Organization:	Ohio Bureau Of Radiation Protection
Reporting

Agreement State
Time - Person (Reporting Time:+33.53 h1.397 days <br />0.2 weeks <br />0.0459 months <br />)
Opened:	Michael Rubadue 13:32 Jun 27, 2019
NRC Officer:	Jeffrey Whited
Last Updated:	Jul 17, 2019
54136 - NRC Website
v • d • e

v t e Emergency Notification System
The Cleveland Clinic Foundation with Agreement State
WEEKMONTHYEAR2019-06-26T04:00:00 [Table view]
[ENS list for The Cleveland Clinic Foundation]

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