ENS Event | |
|---|---|
07:00 Apr 29, 2020 | |
| Title | Agreement State Report - Medical Underdose During Brachytherapy Treatment |
| Event Description | The following information was received from the state of Nevada via email:
The patient was undergoing radiation treatment using Ir-192 and the high dose rate remote afterloader (Varian VS 2000) in three fractions. There were no problems with fractions one and two. During the third fraction, the vaginal cylinder device was inserted into the patient by the doctor. Unknown to the doctor, the device penetrated through the body wall weakened by previous surgery (according to the doctor, [this is] not unknown following robotic hysterectomies). This penetration allowed the source to move about 4 cm past the treatment area. As a result, the treatment area only received 25 percent volume coverage instead of the planned 95 percent volume coverage. The device was a Varian Remote Afterloader, Model VS 2000, which contained 407 GBq of Ir-192. NMED Report No: NV200007 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 | |
|---|---|
| Nv Div Of Rad Health Reno, Nevada (NRC Region 4) | |
| License number: | 16-12-0016-01 |
| Organization: | Nv Div Of Rad Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+35.85 h1.494 days <br />0.213 weeks <br />0.0491 months <br />) | |
| Opened: | Corey Crevling 18:51 Apr 30, 2020 |
| NRC Officer: | Howie Crouch |
| Last Updated: | Apr 30, 2020 |
| 54685 - NRC Website | |
Nv Div Of Rad Health with Agreement State | |
WEEKMONTHYEARENS 546852020-04-29T07:00:00029 April 2020 07:00:00
[Table view]Agreement State Agreement State Report - Medical Underdose During Brachytherapy Treatment ENS 546862020-03-20T07:00:00020 March 2020 07:00:00 Agreement State Agreement State Report - Brachytherapy Underdose Due to an Error in the Treatment Plan 2020-04-29T07:00:00 | |