ENS 54280

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v t e ENS Event
04:00 Sep 11, 2019
Title	Agreement State Report - Misadministration of High Dose Rate Therapy
Event Description	The following was received via email from the Massachusetts Department of Public Health - Radiation Control Program (the Agency): On 09/13/19, a medical event was reported by Massachusetts General Hospital (MGH) (the licensee) involving the medical misadministration of HDR [high dose rate] therapy. The 59 year-old patient involved received dose to unintended tissue exceeding 50 percent of the prescribed dose defined in the written directive. The prescribed dose was 5.5 Gy over 5 fractions for a total of 27.5 Gy to the cervix. The therapy was performed using a Syeb-Neblett Template and 6 catheters including 1 tandem. The patient ultimately received the full intended dose to the tumor (high risk- CTV [clinical target volume]) and per the licensee there was no overdose to any critical structures including bladder, rectum, or bowel. A small region of the surface of the right vaginal wall (approximately 1 cm) did inadvertently receive 16.5 Gy due to the wrong treatment distances being entered into the treatment planning system for 2 of the 7 catheters by the physicist. The patient is not expected to be at an increased risk for toxicity due to this error. Both the patient and referring physician were immediately notified upon discovery. Licensee to submit written report within 15 days of discovery date. The Agency considers this event to be open and pending investigation. 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.

ENS 54280 +/-
Where
Massachusetts General Hospital Boston, Massachusetts (NRC Region 1)
License number:	60-0055
Organization:	Ma Radiation Control Program
Reporting

Agreement State
Time - Person (Reporting Time:+60.47 h2.52 days <br />0.36 weeks <br />0.0828 months <br />)
Opened:	Szymon Mudrewicz 16:28 Sep 13, 2019
NRC Officer:	Ossy Font
Last Updated:	Sep 13, 2019
54280 - NRC Website
v • d • e

v t e Emergency Notification System
Massachusetts General Hospital with Agreement State
WEEKMONTHYEAR2022-08-02T19:30:00 [Table view]
[ENS list for Massachusetts General Hospital]

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