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. |
| 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 | |
Massachusetts General Hospital with Agreement State | |
WEEKMONTHYEARENS 560292022-08-02T19:30:0002 August 2022 19:30:00
[Table view]Agreement State Underdose of Y-90 SIR-SPHERES ENS 542802019-09-11T04:00:00011 September 2019 04:00:00 Agreement State Agreement State Report - Misadministration of High Dose Rate Therapy ENS 498492014-02-19T05:00:00019 February 2014 05:00:00 Agreement State Agreement State Report - Underdose of Y-90 to a Patient ENS 493542013-09-18T04:00:00018 September 2013 04:00:00 Agreement State Agreement State Report - Underdose to Patient'S Liver ENS 465772011-01-13T05:00:00013 January 2011 05:00:00 Agreement State Agreement State Report - Potential Dose Exceeding Annual Occupational Dose Limit for Adults 2022-08-02T19:30:00 | |